Provider Demographics
NPI:1932192622
Name:SOUTHWEST ILLINOIS HEALTH SERVICES, LLP
Entity Type:Organization
Organization Name:SOUTHWEST ILLINOIS HEALTH SERVICES, LLP
Other - Org Name:PET/CT IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSMANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-257-5607
Mailing Address - Street 1:4000 NORTH ILLINOIS
Mailing Address - Street 2:SUITE A
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1496
Mailing Address - Country:US
Mailing Address - Phone:618-236-9770
Mailing Address - Fax:618-236-9780
Practice Address - Street 1:4000 NORTH ILLINOIS
Practice Address - Street 2:SUITE A
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1496
Practice Address - Country:US
Practice Address - Phone:618-236-9770
Practice Address - Fax:618-236-9780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL-01836-012085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid