Provider Demographics
NPI:1144283300
Name:SOUTHERN ILLINOIS CONSULTANTS FOR KIDNEY DISEASE, S.C.
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS CONSULTANTS FOR KIDNEY DISEASE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-244-4850
Mailing Address - Street 1:PO BOX 1704
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-0034
Mailing Address - Country:US
Mailing Address - Phone:618-244-4850
Mailing Address - Fax:618-244-7985
Practice Address - Street 1:416 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-4314
Practice Address - Country:US
Practice Address - Phone:618-244-4850
Practice Address - Fax:618-244-7985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-007470174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4123105OtherBLUE CROSS BLUE SHIELD
IL3523854003Medicaid
L75422Medicare ID - Type UnspecifiedSTEVEN ZELMAN, M.D.
IL3523854003Medicaid