Provider Demographics
NPI:1831101807
Name:PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS INC.
Entity type:Organization
Organization Name:PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE SMGSMG
Authorized Official - Prefix:
Authorized Official - First Name:DELAND
Authorized Official - Middle Name:
Authorized Official - Last Name:EVISCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-899-1040
Mailing Address - Street 1:4218 LINCOLNSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2156
Mailing Address - Country:US
Mailing Address - Phone:618-899-3600
Mailing Address - Fax:
Practice Address - Street 1:4218 LINCOLNSHIRE DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2156
Practice Address - Country:US
Practice Address - Phone:618-899-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207V00000X, 207Y00000X, 208000000X, 208600000X, 208G00000X, 363A00000X, 207R00000X
IL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL208959Medicare Oscar/Certification
IL=========001Medicaid
IL783803Medicare Oscar/Certification
IL211409Medicare Oscar/Certification
IL148998Medicare Oscar/Certification
IL783802Medicare Oscar/Certification
IL143402Medicare Oscar/Certification
IL783803Medicare Oscar/Certification
IL208959Medicare Oscar/Certification