Organization
SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Active
Organization
SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Active
Other names
Good Samaritan Health Center
Organization subpart
No
Provider details
NPI number
Authorized official
MR. LARRY MCCULLEY (PRESIDENT)
(618) 332-0694
Entity
Organization
Contact information
Practice address
815 E 5TH ST, ALTON, IL 62002-6471
(618) 397-3303
(618) 397-7802
Mailing address
8080 STATE ST, EAST SAINT LOUIS, IL 62203-1808
(618) 397-3303
(618) 397-7802
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14-1089
NGS MEDICARE
IL
01
—
732740
WPS MEDICARE PART B
IL
Enumeration date
06/25/2008
Last updated
07/22/2009
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