Provider Demographics
NPI:1720081805
Name:HOSPICE OF SOUTHERN ILLINOIS, INC.
Entity type:Organization
Organization Name:HOSPICE OF SOUTHERN ILLINOIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WISDOM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:618-235-1703
Mailing Address - Street 1:305 S ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-2133
Mailing Address - Country:US
Mailing Address - Phone:618-235-1703
Mailing Address - Fax:618-235-3130
Practice Address - Street 1:305 S ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-2133
Practice Address - Country:US
Practice Address - Phone:618-235-1703
Practice Address - Fax:618-235-3130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2000115251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid