Provider Demographics
NPI:1538689062
Name:SOUTHERN ILLINOIS MEDICAL SERVICES, NFP
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS MEDICAL SERVICES, NFP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:P
Authorized Official - Last Name:LADNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-457-5200
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:98 PEACH RIDGE RD
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-2243
Practice Address - Country:US
Practice Address - Phone:618-614-1400
Practice Address - Fax:618-614-1401
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN ILLINOIS HOSPITAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-26
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1770656837Medicaid