Provider Demographics
NPI:1689739062
Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-332-0783
Mailing Address - Street 1:8080 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-1808
Mailing Address - Country:US
Mailing Address - Phone:618-397-3303
Mailing Address - Fax:618-397-7802
Practice Address - Street 1:800 RANGE LN
Practice Address - Street 2:
Practice Address - City:CAHOKIA
Practice Address - State:IL
Practice Address - Zip Code:62206-2022
Practice Address - Country:US
Practice Address - Phone:618-337-3117
Practice Address - Fax:618-337-3122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchoolGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========013Medicaid