Provider Demographics
NPI:1831337450
Name:PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS
Entity type:Organization
Organization Name:PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MNG
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SIMONTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-436-6267
Mailing Address - Street 1:4218 LINCOLNSHIRE DR
Mailing Address - Street 2:PO BOX 968
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2156
Mailing Address - Country:US
Mailing Address - Phone:618-532-9350
Mailing Address - Fax:
Practice Address - Street 1:4218 LINCOLNSHIRE DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2156
Practice Address - Country:US
Practice Address - Phone:618-532-9350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSCIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113387208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211409Medicare Oscar/Certification