Provider Demographics
NPI:1912347485
Name:SOUTHERNMOST ILLINOIS COMMUNITY HEALTH IMPROVEMENT CORPORATION
Entity Type:Organization
Organization Name:SOUTHERNMOST ILLINOIS COMMUNITY HEALTH IMPROVEMENT CORPORATION
Other - Org Name:CAIRO DIAGNOSTIC CENTER LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERNSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-457-0450
Mailing Address - Street 1:13289 KESSLER RD
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:IL
Mailing Address - Zip Code:62914-3101
Mailing Address - Country:US
Mailing Address - Phone:618-734-1500
Mailing Address - Fax:618-734-9152
Practice Address - Street 1:13289 KESSLER RD
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:IL
Practice Address - Zip Code:62914-3101
Practice Address - Country:US
Practice Address - Phone:618-734-1500
Practice Address - Fax:618-734-9152
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERNMOST ILLINOIS COMMUNITY HEALTH IMPROVEMENT CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-28
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
14D0436489OtherCLIA#
575090Medicare PIN