Provider Demographics
NPI:1831254234
Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-332-0694
Mailing Address - Street 1:8080 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-1808
Mailing Address - Country:US
Mailing Address - Phone:618-397-3303
Mailing Address - Fax:618-397-7802
Practice Address - Street 1:3939 CASEYVILLE AVE
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62204-2448
Practice Address - Country:US
Practice Address - Phone:618-482-4562
Practice Address - Fax:618-482-4930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LS0200X, 261QF0400X
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchoolGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty