Provider Demographics
NPI:1396097960
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:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:R
Authorized Official - Last Name:ALBERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-757-8100
Mailing Address - Street 1:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-4410
Practice Address - Street 1:520 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5238
Practice Address - Country:US
Practice Address - Phone:217-757-8100
Practice Address - Fax:217-747-1351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care