Provider Demographics
NPI:1962427856
Name:SOUTHERN ILLINOIS ASSOCIATES LLC
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:NIGAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-288-5019
Mailing Address - Street 1:6805 STATE ROUTE 162 STE 201
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8530
Mailing Address - Country:US
Mailing Address - Phone:618-288-5019
Mailing Address - Fax:618-288-5059
Practice Address - Street 1:6805 STATE ROUTE 162 STE 201
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8530
Practice Address - Country:US
Practice Address - Phone:618-288-5019
Practice Address - Fax:618-288-5059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361070242084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty