Provider Demographics
NPI:1215978127
Name:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Entity type:Organization
Organization Name:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-545-8137
Mailing Address - Street 1:201 E MADISON ST STE 328
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5131
Mailing Address - Country:US
Mailing Address - Phone:217-545-6523
Mailing Address - Fax:217-545-4410
Practice Address - Street 1:300 W OAK ST STE 100
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1496
Practice Address - Country:US
Practice Address - Phone:618-453-3777
Practice Address - Fax:618-453-1102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCE8688OtherRR MEDICARE
ILCE8687OtherRR MEDICARE
ILCE8689OtherRR MEDICARE
ILCE8931OtherRR MEDICARE
ILCB2589OtherRR HEALTH
ILCE8686OtherRR MEDICARE
IL=========008Medicaid
ILCE8687OtherRR MEDICARE