| Board Of Trustees Of Southern Illinois University | |
|
303 E Bidwell St Taylorville IL 62568-1363 | |
| (217) 824-3566 | |
| Not Available |
| Full Name | Board Of Trustees Of Southern Illinois University |
|---|---|
| Speciality | Clinic/Center |
| Location | 303 E Bidwell St, Taylorville, 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 303 E Bidwell St Taylorville IL 62568-1363 Ph: (217) 824-3566 |
| NPI Number | 1851934871 |
|---|---|
| Provider Enumeration Date | 10/22/2019 |
| Last Update Date | 10/22/2019 |
| Medicare PECOS PAC ID | 4486667888 |
|---|---|
| Medicare Enrollment ID | O20200309002148 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1851934871 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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