NPIMap

Organization Active NPI

Board of Trustees of Southern Illinois University

  • Nurse Practitioner
  • East Saint Louis, IL
National Provider Identifier
1104230168
Registry record updated Jul 15, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse PractitionerTaxonomy code 363L00000X
Legal business name
BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Practice address
601 James R Thompson Blvd
Building D, Suite 2015
East Saint Louis, IL 62201-1129
Phone
(618) 482-6959
Fax
(618) 482-8311
NPI assigned
Jun 18, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 15, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Myjal Garner, DNP, APRN, FNP-CNPI 1598435372
Title
Director
Phone
(618) 482-6959

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Multi-Specialty Clinic/Center 261QM1300X
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X Primary

Addresses

Primary practice location

601 James R Thompson Blvd
Building D, Suite 2015
East Saint Louis, IL 62201-1129

Mailing address

601 James R Thompson Blvd
Building D, Suite 2015
East Saint Louis, IL 62201-1129
Phone (618) 482-6959

Other names 1

  • Southern Illinois University Edwardsville Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140728002465 IL Part B Supplier - Clinic/Group Practice 3173749157 Receives reassigned benefits from 2 practitioners
Practice locations: East Saint Louis, IL; East St. Louis, IL

National Provider Directory

National Provider Directory
Tax ID family
Southern Illinois Univ6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

Locations

601 James R Thompson Blvd
East Saint Louis, IL 62201
Phone (618) 482-6939

601 James R Thompson Blvd
#2015
East Saint Louis, IL 62201
Phone (618) 482-6959

601 James R Thompson Blvd
Ste 2015
East Saint Louis, IL 62201
Phone (618) 482-6959

601 James R Thompson Blvd
Bldg D
East Saint Louis, IL 62201
Phone (573) 882-3629

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1403049600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1784073600000",
    "number": "1104230168",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "601 JAMES R THOMPSON BLVD",
            "address_2": "BUILDING D, SUITE 2015",
            "city": "EAST SAINT LOUIS",
            "state": "IL",
            "postal_code": "622011129",
            "telephone_number": "618-482-6959",
            "fax_number": "618-482-8311"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "601 JAMES R THOMPSON BLVD",
            "address_2": "BUILDING D, SUITE 2015",
            "city": "EAST SAINT LOUIS",
            "state": "IL",
            "postal_code": "622011129",
            "telephone_number": "618-482-6959",
            "fax_number": "618-482-8311"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-06-18",
        "last_updated": "2026-07-15",
        "certification_date": "2026-07-15",
        "status": "A",
        "authorized_official_last_name": "GARNER",
        "authorized_official_first_name": "MYJAL",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "618-482-6959",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DNP, APRN, FNP-C"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southern Illinois University Edwardsville",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in East Saint Louis, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.