Provider Demographics
NPI:1215243001
Name:SOUTHERN ILLINOIS CASE COORDINATION SERVICES
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS CASE COORDINATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:HAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-532-4300
Mailing Address - Street 1:519 S LOCUST ST # 588
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-4223
Mailing Address - Country:US
Mailing Address - Phone:618-532-4300
Mailing Address - Fax:618-532-9416
Practice Address - Street 1:519 S LOCUST ST # 588
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-4223
Practice Address - Country:US
Practice Address - Phone:618-532-4300
Practice Address - Fax:618-532-9416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
IL40CM001645251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management