Provider Demographics
NPI:1932441946
Name:THE BOARD OF TRUSTEES OF SIU GOVERNING SIUE
Entity Type:Organization
Organization Name:THE BOARD OF TRUSTEES OF SIU GOVERNING SIUE
Other - Org Name:DEPARTMENT: SIUE HEALTH SERVICE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR, HEALTH SERVICE
Authorized Official - Prefix:
Authorized Official - First Name:RIANE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GREENWALT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-650-2852
Mailing Address - Street 1:STUDENT SUCCESS CTR RM 0222
Mailing Address - Street 2:CAMPUS BOX 1055
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62026-1055
Mailing Address - Country:US
Mailing Address - Phone:618-650-2850
Mailing Address - Fax:618-650-5839
Practice Address - Street 1:STUDENT SUCCESS CTR RM 0222
Practice Address - Street 2:CAMPUS BOX 1055
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-1055
Practice Address - Country:US
Practice Address - Phone:618-650-2850
Practice Address - Fax:618-650-5839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-18
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health