Provider Demographics
NPI:1023151461
Name:SOUTHERN ILLINOIS UNIVERSITY
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR SIU STUDENT HEALTH CENTER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PRESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:618-453-4485
Mailing Address - Street 1:374 EAST GRAND AVENUE
Mailing Address - Street 2:MAIL CODE 674D
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901
Mailing Address - Country:US
Mailing Address - Phone:618-453-3311
Mailing Address - Fax:618-453-4449
Practice Address - Street 1:374 EAST GRAND AVENUE
Practice Address - Street 2:MAIL CODE 674D
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-453-3311
Practice Address - Fax:618-453-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PH5000Medicare UPIN