Organization
BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Active
Other names
DEPARTMENT OF PSYCHIATRY
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID J TKACH (CEO)
(217) 545-7578
Entity
Organization
Contact information
Practice address
901 W JEFFERSON ST, SPRINGFIELD, IL 62702-4833
(217) 545-8229
(217) 545-2275
Mailing address
PO BOX 19642, SPRINGFIELD, IL 62794-9642
(217) 545-8229
(217) 545-2275
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
10-0066401
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100066401002
—
IL
Enumeration date
02/20/2008
Last updated
06/19/2008
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