Provider Demographics
NPI:1487070835
Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Other - Org Name:<UNAVAIL>
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 1:626 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2444
Practice Address - Country:US
Practice Address - Phone:217-345-7702
Practice Address - Fax:217-345-7705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-10
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========071Medicaid
IL=========071Medicaid