Provider Demographics
NPI:1720175193
Name:SOUTHERN ILLINOIS ALLERGY&ASTHMA CENTER,SC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS ALLERGY&ASTHMA CENTER,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:MINGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-549-9385
Mailing Address - Street 1:1001 E MAIN ST
Mailing Address - Street 2:2A PPE
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3100
Mailing Address - Country:US
Mailing Address - Phone:618-549-9385
Mailing Address - Fax:618-549-8795
Practice Address - Street 1:1001 E MAIN ST
Practice Address - Street 2:2A PPE
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3100
Practice Address - Country:US
Practice Address - Phone:618-549-9385
Practice Address - Fax:618-549-8795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03927935OtherBLUE CROSS/BLUE SHIELD
IL027533OtherHEALTH ALLIANCE
IL101269OtherHEALTHLINK
ILC 43894Medicare UPIN
IL03927935OtherBLUE CROSS/BLUE SHIELD