| Board Of Trustees Of Southern Illinois University | |
|
425 E State St., Ste 100 Jacksonville IL 62650-2125 | |
| (217) 545-8000 | |
| Not Available |
| Full Name | Board Of Trustees Of Southern Illinois University |
|---|---|
| Speciality | Clinic/Center |
| Location | 425 E State St., Ste 100, Jacksonville, Illinois |
| Authorized Official Name and Position | Shelby Renee Burdick (TEAM LEAD, MEDICAL STAFF SERVICES) |
| Authorized Official Contact | 2175456523 |
| 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 201 E Madison St Ste 328 Springfield IL 62702-5131 Ph: (217) 545-8000 | Board Of Trustees Of Southern Illinois University 425 E State St., Ste 100 Jacksonville IL 62650-2125 Ph: (217) 545-8000 |
| NPI Number | 1598412447 |
|---|---|
| Provider Enumeration Date | 03/09/2022 |
| Last Update Date | 03/09/2022 |
| Medicare PECOS PAC ID | 4486667888 |
|---|---|
| Medicare Enrollment ID | O20220414001368 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1598412447 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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