Provider Demographics
NPI:1871882787
Name:SIU PHYSICIANS & SURGEONS, INC
Entity type:Organization
Organization Name:SIU PHYSICIANS & SURGEONS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-545-7876
Mailing Address - Street 1:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-7578
Mailing Address - Fax:217-545-1884
Practice Address - Street 1:315 W CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4901
Practice Address - Country:US
Practice Address - Phone:217-545-5817
Practice Address - Fax:217-545-1141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RH0000X, 207RX0202X, 3336C0003X
IL332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0286180015Medicare PIN