Southern Illinois Healthcare Foundation, Inc

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

Legal business name

SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC

Doing business as

Koch Health Center

Practice address

2100 Madison Ave
Granite City, IL 62040-4701

Phone

(618) 452-3301

Fax

(618) 452-3312

NPI assigned

Jun 23, 2006

Organization subpart

No

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

Authorized official

Name

Mr. Larry McCulley

Title

Chief Operating Officer

Phone

(618) 332-0783

Specialties & licenses 4

Addresses

Other identifiers 1

Other names 1

• Koch Health Center Doing business as

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

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

{
    "created_epoch": "1151020800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1208649600000",
    "number": "1801822010",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8080 STATE ST",
            "city": "EAST SAINT LOUIS",
            "state": "IL",
            "postal_code": "622031808",
            "telephone_number": "618-397-3303",
            "fax_number": "618-397-7802"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2100 MADISON AVE",
            "city": "GRANITE CITY",
            "state": "IL",
            "postal_code": "620404701",
            "telephone_number": "618-452-3301",
            "fax_number": "618-452-3312"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-23",
        "last_updated": "2008-04-20",
        "status": "A",
        "authorized_official_last_name": "MCCULLEY",
        "authorized_official_first_name": "LARRY",
        "authorized_official_title_or_position": "CHIEF OPERATING OFFICER",
        "authorized_official_telephone_number": "618-332-0783",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WPS MEDICARE GROUP NUMBER",
            "identifier": "732740",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Koch Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Mavis Lynne Smith, RPH
• Zachary Smith
• Timothy E Snyder, CRADC
• Kim Ann Sorgea, PTA
• Southern Illinois Healthcare Foundation, Inc
• Southern Illinois Healthcare Foundation, Inc.
• Southern Illinois Healthcare Foundation, Inc.
• Southern Illinois Healthcare Foundation, Inc.
• Southern Illinois Healthcare Foundation, Inc.
• Southern Illinois Healthcare Foundation, Inc.

• Federally Qualified Health Center (FQHC) in Granite City, IL
• Providers in Granite City, IL by specialty
• Federally Qualified Health Center (FQHC) in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 20, 2008; 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.