Provider Demographics
NPI:1548264237
Name:PHYSICIAN SERVICES CORP OF SOUTHERN ILLINOIS
Entity type:Organization
Organization Name:PHYSICIAN SERVICES CORP OF SOUTHERN ILLINOIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCIAL DEVELOPMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-241-2204
Mailing Address - Street 1:413 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-532-9350
Mailing Address - Fax:
Practice Address - Street 1:8 CUSUMANO PROFESSIONAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6736
Practice Address - Country:US
Practice Address - Phone:618-242-7819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICIAN SERVICES CORP OF SOUTHERN ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-09
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0004705261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL430653587005Medicaid
IL143402Medicare Oscar/Certification
IL783802Medicare Oscar/Certification