Provider Demographics
NPI:1982738274
Name:INTEGRATED HEALTH OF SOUTHERN ILLINOIS, LTD.
Entity Type:Organization
Organization Name:INTEGRATED HEALTH OF SOUTHERN ILLINOIS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HESTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-252-5555
Mailing Address - Street 1:303 S COMMERCIAL ST
Mailing Address - Street 2:STE 10
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-2125
Mailing Address - Country:US
Mailing Address - Phone:618-252-5555
Mailing Address - Fax:618-252-2279
Practice Address - Street 1:303 S COMMERCIAL ST
Practice Address - Street 2:STE 10
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2125
Practice Address - Country:US
Practice Address - Phone:618-252-5555
Practice Address - Fax:618-252-2279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-619186111N00000X
IL042620395207QS0010X
IL042619186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209925OtherMEDICARE PTAN