Provider Demographics
NPI:1154725976
Name:PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS INC
Entity type:Organization
Organization Name:PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE SMGSMG
Authorized Official - Prefix:MR
Authorized Official - First Name:DELAND
Authorized Official - Middle Name:
Authorized Official - Last Name:EVISCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-899-1040
Mailing Address - Street 1:602 S 42ND ST STE B
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6264
Mailing Address - Country:US
Mailing Address - Phone:618-899-3278
Mailing Address - Fax:618-242-1853
Practice Address - Street 1:602 S 42ND ST STE B
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6264
Practice Address - Country:US
Practice Address - Phone:618-899-3278
Practice Address - Fax:618-242-1853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site