Provider Demographics
| NPI: | 1427071646 |
|---|---|
| Name: | SIU PHYSICIANS & SURGEONS, INC |
| Entity type: | Organization |
| Organization Name: | SIU PHYSICIANS & SURGEONS, INC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CEO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | DAVID |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | TKACH |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 217-545-7578 |
| 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: | 217-545-7578 |
| Mailing Address - Fax: | 217-545-1884 |
| Practice Address - Street 1: | 701 N 1ST ST |
| Practice Address - Street 2: | D235 |
| Practice Address - City: | SPRINGFIELD |
| Practice Address - State: | IL |
| Practice Address - Zip Code: | 62781-0001 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 217-545-7578 |
| Practice Address - Fax: | 217-545-1884 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-07-26 |
| Last Update Date: | 2022-07-21 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| IL | 133V00000X, 225XH1200X, 231H00000X, 363AM0700X, 363AS0400X, 363LA2100X, 363LA2200X, 363LF0000X, 363LN0000X, 363LP0200X, 364SG0600X, 364SX0200X, 367A00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
| No | 133V00000X | Dietary & Nutritional Service Providers | Dietitian, Registered | Group - Multi-Specialty | |
| No | 225XH1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | Group - Multi-Specialty |
| No | 231H00000X | Speech, Language and Hearing Service Providers | Audiologist | Group - Multi-Specialty | |
| No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
| No | 363LA2100X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | Group - Multi-Specialty |
| No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
| No | 363LN0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | Group - Multi-Specialty |
| No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | Group - Multi-Specialty |
| No | 364SG0600X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology | Group - Multi-Specialty |
| No | 364SX0200X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Oncology | Group - Multi-Specialty |
| No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| IL | CB2589 | Other | RR MEDICARE |
| IL | CE8931 | Other | RR MEDICARE |
| IL | CE8687 | Other | RR MEDICARE |
| IL | CE8686 | Other | RR MEDICARE |
| IL | CE8689 | Other | RR MEDICARE |
| IL | CE8688 | Other | RR MEDICARE |
| IL | 529270 | Medicare PIN | |
| IL | 256512 | Medicare PIN | |
| IL | CE8688 | Other | RR MEDICARE |
| IL | CE8931 | Other | RR MEDICARE |
| IL | 208343 | Medicare PIN | |
| IL | 203144 | Medicare PIN | |
| IL | 550520 | Medicare PIN | |
| IL | 200902 | Medicare PIN | |
| IL | CE8689 | Other | RR MEDICARE |
