Provider Demographics
NPI:1215925102
Name:HEALTH PLAN OF SOUTHERN ILLINOIS, INC.
Entity type:Organization
Organization Name:HEALTH PLAN OF SOUTHERN ILLINOIS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-439-3706
Mailing Address - Street 1:205 BAILEY LN
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1921
Mailing Address - Country:US
Mailing Address - Phone:618-439-3706
Mailing Address - Fax:618-435-2023
Practice Address - Street 1:205 BAILEY LN
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1921
Practice Address - Country:US
Practice Address - Phone:618-439-3706
Practice Address - Fax:618-435-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2815503OtherBCBS
IL=========005Medicaid
143802Medicare Oscar/Certification
IL2815503OtherBCBS
ILD10775Medicare UPIN