Provider Demographics
NPI:1104988971
Name:SOUTHERN ILLINOIS CENTER FOR HEALTH
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS CENTER FOR HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:REBHOLZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-939-3939
Mailing Address - Street 1:509 HAMACHER ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1592
Mailing Address - Country:US
Mailing Address - Phone:618-939-3939
Mailing Address - Fax:618-939-3941
Practice Address - Street 1:509 HAMACHER ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-3939
Practice Address - Fax:618-939-3941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherEIN
382061Medicare PIN