Provider Demographics
NPI:1932432143
Name:ORTHOPAEDIC CENTER OF SOUTHERN ILLINOIS, LTD.
Entity Type:Organization
Organization Name:ORTHOPAEDIC CENTER OF SOUTHERN ILLINOIS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN BENOIT
Authorized Official - Middle Name:
Authorized Official - Last Name:HOULE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-242-3778
Mailing Address - Street 1:4121 VETERANS MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6262
Mailing Address - Country:US
Mailing Address - Phone:618-242-3778
Mailing Address - Fax:618-242-2551
Practice Address - Street 1:839 M L KING DRIVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3001
Practice Address - Country:US
Practice Address - Phone:618-545-0894
Practice Address - Fax:618-545-0914
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHOPAEDIC CENTER OF SOUTHERN ILLINOIS, LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-08
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CN2166OtherRR MEDICARE PIN
CN2166OtherRR MEDICARE PIN