| Board Of Trustees Of Southern Illinois University | |
|
205 S 24th St Ste 100 Quincy IL 62301-4446 | |
| (217) 224-9484 | |
| (217) 224-7950 |
| Full Name | Board Of Trustees Of Southern Illinois University |
|---|---|
| Speciality | Clinic/Center |
| Location | 205 S 24th St Ste 100, Quincy, 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) 545-7876 | Board Of Trustees Of Southern Illinois University 205 S 24th St Ste 100 Quincy IL 62301-4446 Ph: (217) 224-9484 |
| NPI Number | 1215578109 |
|---|---|
| Provider Enumeration Date | 10/02/2019 |
| Last Update Date | 10/02/2019 |
| Medicare PECOS PAC ID | 4486667888 |
|---|---|
| Medicare Enrollment ID | O20191014001734 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1215578109 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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