| Southern Illinois Neuropsychology Llc | |
|
60 S State Route 157 Edwardsville IL 62025 | |
| (618) 391-4021 | |
| Not Available |
| Full Name | Southern Illinois Neuropsychology Llc |
|---|---|
| Speciality | Clinical Neuropsychologist |
| Location | 60 S State Route 157, Edwardsville, Illinois |
| Authorized Official Name and Position | Phillip Ruppert (OWNER) |
| Authorized Official Contact | 6183914021 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southern Illinois Neuropsychology Llc 1 Oak Dr Unit 352 Maryville IL 62062-7026 Ph: (618) 391-4021 | Southern Illinois Neuropsychology Llc 60 S State Route 157 Edwardsville IL 62025 Ph: (618) 391-4021 |
| NPI Number | 1861909509 |
|---|---|
| Provider Enumeration Date | 01/03/2018 |
| Last Update Date | 02/10/2022 |
| Certification Date | 02/10/2022 |
| Medicare PECOS PAC ID | 8729347695 |
|---|---|
| Medicare Enrollment ID | O20180123000255 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1861909509 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103G00000X | Clinical Neuropsychologist | 071009269 (Illinois) | Primary |
| Provider Name | Phillip D Ruppert |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1861771206 PECOS PAC ID: 9830330034 Enrollment ID: I20180123000316 |
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