Provider Demographics
NPI:1770656837
Name:SOUTHERN ILLINOIS MEDICAL SERVICES, NFP
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS MEDICAL SERVICES, NFP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:P
Authorized Official - Last Name:LADNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-457-5200
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:1239 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-457-5200
Practice Address - Fax:618-549-5128
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN ILLINOIS HOSPITAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-16
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3932056OtherBCBS
IL3932056OtherBCBS
IL214881Medicare PIN