Organization
SIU PHYSICIANS & SURGEONS, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID TKACH (CEO)
(217) 545-7578
Entity
Organization
Contact information
Practice address
701 N 1ST ST, D235, SPRINGFIELD, IL 62781-0001
(217) 545-7578
(217) 545-1884
Mailing address
PO BOX 19639, SPRINGFIELD, IL 62794-9639
(217) 545-7578
(217) 545-1884
Taxonomy
Speciality
Code
Description
License number
State
207SG0201X
Clinical Genetics (M.D.) Physician
—
IL
208000000X
Pediatrics Physician
Primary
—
IL
2080P0006X
Developmental - Behavioral Pediatrics Physician
—
IL
2080P0206X
Pediatric Gastroenterology Physician
—
IL
2080P0208X
Pediatric Infectious Diseases Physician
—
IL
2080P0210X
Pediatric Nephrology Physician
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CB2589
RR MEDICARE
IL
01
—
CE8686
RR MEDICARE
IL
01
—
CE8687
RR MEDICARE
IL
01
—
CE8688
RR MEDICARE
IL
01
—
CE8689
RR MEDICARE
IL
01
—
CE8931
RR MEDICARE
IL
Enumeration date
07/26/2006
Last updated
07/21/2022
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