Provider Demographics
NPI:1982446076
Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-332-0694
Mailing Address - Street 1:2041 GOOSE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SAUGET
Mailing Address - State:IL
Mailing Address - Zip Code:62206-2822
Mailing Address - Country:US
Mailing Address - Phone:618-332-0953
Mailing Address - Fax:618-332-2487
Practice Address - Street 1:311 W LINCOLN ST STE 200
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1902
Practice Address - Country:US
Practice Address - Phone:618-213-7943
Practice Address - Fax:618-213-7944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty