Provider Demographics
NPI:1104807056
Name:SOUTHERN ILLINOIS SURGICAL APPLIANCE CO
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS SURGICAL APPLIANCE CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-932-3157
Mailing Address - Street 1:19 W FRANKFORT PLZ
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-4964
Mailing Address - Country:US
Mailing Address - Phone:618-932-3157
Mailing Address - Fax:618-932-3031
Practice Address - Street 1:19 W FRANKFORT PLZ
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-4964
Practice Address - Country:US
Practice Address - Phone:618-932-3157
Practice Address - Fax:618-932-3031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2032-1120332BX2000X
IL2032 1120332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid