| Board Of Trustees Of Southern Illinois University | |
|
2833 S Grand Ave E Springfield IL 62703-2175 | |
| (221) 753-5310 | |
| (217) 789-2069 |
| Full Name | Board Of Trustees Of Southern Illinois University |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 2833 S Grand Ave E, Springfield, Illinois |
| Authorized Official Name and Position | Iris Wesley (CEO) |
| Authorized Official Contact | 2175458000 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Board Of Trustees Of Southern Illinois University Po Box 19670 Springfield IL 62794-9670 Ph: (217) 535-3102 | Board Of Trustees Of Southern Illinois University 2833 S Grand Ave E Springfield IL 62703-2175 Ph: (221) 753-5310 |
| NPI Number | 1023585312 |
|---|---|
| Provider Enumeration Date | 10/25/2018 |
| Last Update Date | 10/25/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1023585312 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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