| Board Of Trustees Of Southern Illinois University | |
|
300 W Oak Street Carbondale IL 62901 | |
| (618) 536-6621 | |
| (618) 453-1102 |
| Full Name | Board Of Trustees Of Southern Illinois University |
|---|---|
| Speciality | Clinic/Center |
| Location | 300 W Oak Street, Carbondale, Illinois |
| Authorized Official Name and Position | Iris Wesley (CEO) |
| Authorized Official Contact | 2175458000 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Board Of Trustees Of Southern Illinois University Po Box 19639 Springfield IL 62794-9639 Ph: (217) 545-7578 | Board Of Trustees Of Southern Illinois University 300 W Oak Street Carbondale IL 62901 Ph: (618) 536-6621 |
| NPI Number | 1437708674 |
|---|---|
| Provider Enumeration Date | 09/10/2019 |
| Last Update Date | 09/10/2019 |
| Medicare PECOS PAC ID | 4486667888 |
|---|---|
| Medicare Enrollment ID | O20191008000423 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1437708674 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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