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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