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
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
IL
101YP2500X
Professional Counselor
—
IL
103G00000X
Clinical Neuropsychologist
—
IL
103T00000X
Psychologist
—
IL
103TC0700X
Clinical Psychologist
—
IL
1041C0700X
Clinical Social Worker
—
IL
2084N0400X
Neurology Physician
Primary
—
IL
2084N0402X
Neurology with Special Qualifications in Child Neurology Physician
—
IL
2084P0800X
Psychiatry Physician
—
IL
2084P0804X
Child & Adolescent Psychiatry 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
07/27/2006
Last updated
07/21/2022
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