Organization
SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Active
Organization
SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Active
Other names
Belleville Pediatric & Adolescent Health Center
Organization subpart
No
Provider details
NPI number
Authorized official
MR. LARRY MCCULLEY (CEO)
(618) 332-0694
Entity
Organization
Contact information
Practice address
2900 FRANK SCOTT PKWY W, SUITE 950, BELLEVILLE, IL 62223-5000
(618) 233-3205
(618) 233-1407
Mailing address
2041 GOOSE LAKE RD, SAUGET, IL 62206-2822
(618) 332-0953
(618) 332-2487
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
—
—
1041C0700X
Clinical Social Worker
—
—
208000000X
Pediatrics Physician
—
—
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
732740
WPS MEDICARE
IL
Enumeration date
06/18/2006
Last updated
08/08/2014
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