BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY (NPI# 1407376338) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1407376338 |
| Entity Type | Organization |
| Organization Name | BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY |
| Other Organization Name | SIU CENTER FOR FAMILY MEDICINE - DECATUR |
| Practice Address |
102 W Kenwood Ave Decatur IL 62526-4368 |
| Mailing Address |
Po Box 19639 Springfield IL 62794-9639 |
| Practice Telephone | 2178723800 |
| Practice Fax Number | 2178720849 |
| Mailing Telephone | 2178723800 |
| Mailing Fax Number | 2178720849 |
| Enumeration Date | 2017-06-21 |
| Last Update Date | 2017-06-21 |
| Authorized Official Name | IRIS WESLEY (CHIEF EXECUTIVE OFFICER) |
| Authorized Official Telephone | 2175457876 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 261QF0400X |
Clinic/Center Specialization: Federally Qualified Health Center (FQHC) |
IL | Ambulatory Health Care Facilities |
| Other Name | Type Code |
|---|---|
| SIU Center for Family Medicine - Decatur | Other Name - Individual/Organization |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1396386181 | Board of Trustees of Southern Illinois University | Clinic/Center | 300 W Oak St Ste 100, Carbondale, IL 62901-1496 | 2019-10-02 |
| 1215578109 | Board of Trustees of Southern Illinois University | Clinic/Center | 205 S 24th St Ste 100, Quincy, IL 62301-4446 | 2019-10-02 |
| 1437708674 | Board of Trustees of Southern Illinois University | Clinic/Center | 300 W Oak Street, Carbondale, IL 62901 | 2019-09-10 |
| 1558848473 | Board of Trustees of Southern Illinois University | Clinic/Center | 2833 S Grand Ave E Ste 100, Springfield, IL 62703-2175 | 2018-07-24 |
| 1003324260 | Board of Trustees of Southern Illinois University | Clinic/Center | 4409 Maine St Ste 100, Quincy, IL 62305-5849 | 2018-01-22 |
| 1083121537 | Board of Trustees of Southern Illinois University | Clinic/Center | 330 Vermont St Ste 100, Quincy, IL 62301-2700 | 2018-01-05 |
| 1922515451 | Board of Trustees of Southern Illinois University | Clinic/Center | 330 Vermont St Ste 211, Quincy, IL 62301-2700 | 2018-01-05 |
| 1679188437 | Board of Trustees of Southern Illinois University | Clinic/Center | 751 N Rutledge St Ste 1100, Springfield, IL 62702-4968 | 2020-09-09 |
| 1619501871 | Board of Trustees of Southern Illinois University | Clinic/Center | 606 W Adams St, Pittsfield, IL 62363-1308 | 2020-02-26 |
| 1851934871 | Board of Trustees of Southern Illinois University | Clinic/Center | 303 E Bidwell St, Taylorville, IL 62568-1363 | 2019-10-22 |
| Street Address |
102 W KENWOOD AVE |
| City | DECATUR |
| State | IL |
| Zip Code | 62526-4368 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1376534636 | Jeffrey Bruce Rounds | Specialist/Technologist | 102 W Kenwood Ave, Decatur, IL 62526-4300 | 2005-11-04 |
| 1497277263 | Jonathan Roderick Dutt | Family Medicine | 102 W Kenwood Ave, Decatur, IL 62526-4368 | 2017-07-12 |
| 1992234504 | Nicole Gabriel Tenegra | Family Medicine | 102 W Kenwood Ave, Decatur, IL 62526-4368 | 2017-06-07 |
| 1811340979 | Aimen Naeem | Family Medicine | 102 W Kenwood Ave, Suite 100, Decatur, IL 62526-4368 | 2016-07-13 |
| 1528411683 | Hema Patel | Family Medicine | 102 W Kenwood Ave, Suite 100, Decatur, IL 62526-4368 | 2016-07-13 |
| 1578914867 | Deepti Sood | Family Medicine | 102 W Kenwood Ave, Suite 100, Decatur, IL 62526-4368 | 2016-06-28 |
| 1780065730 | Zeerak Qureshi | Family Medicine | 102 W Kenwood Ave, Ste 100, Decatur, IL 62526-4368 | 2015-06-16 |
| 1780076901 | Audra L Trump | Nurse Practitioner | 102 W Kenwood Ave, Decatur, IL 62526-4368 | 2015-02-25 |
| 1619396736 | Michael Knobeloch | Counselor | 102 W Kenwood Ave, Suite 120a, Decatur, IL 62526-4368 | 2014-04-16 |
| 1932464633 | Alicia Koontz | Physical Therapy Assistant | 102 W Kenwood Ave, Decatur, IL 62526-4368 | 2012-07-09 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1083100804 | Coalition | Non-emergency Medical Transport (VAN) | 2375 N Longwood Dr, Decatur, IL 62526 | 2018-07-04 |
| 1881116820 | Bria N Howard | Nurse's Aide | 606 E Warren St. Apt 609, Decatur, IL 62526 | 2017-07-12 |
| 1437683679 | Lutheran Child and Family Services | Foster Care Agency | 2826 N. Monroe Street, Decatur, IL 62526 | 2017-04-14 |
| 1083166326 | Whitney Miller | Pharmacist | 225 East Ash Ave, Decatur, IL 62526 | 2016-11-03 |
| 1487053369 | Central Illinois Health Associates, Inc | Preferred Provider Organization | 2300 N. Edward Street, Decatur, IL 62526 | 2014-08-18 |
| 1659787893 | Stephanie Marie Kanitsch | Obstetrics & Gynecology | 544 W Pershing Rd Ste A, Decatur, IL 62526 | 2014-07-09 |
| 1497169973 | Brian Hassinger | Audiologist-Hearing Aid Fitter | 2605 N Water St Ste 101, Decatur, IL 62526 | 2014-06-12 |
| 1891041570 | Decatur 2016 LLC | Dentist | 141 Epershing Rd, Decatur, IL 62526 | 2012-07-31 |
| 1558639005 | Larry Lee Christensen | Pharmacist | 225 Ash Ave, Decatur, IL 62526 | 2011-12-12 |
| 1174821540 | Nathan Pyle | Internal Medicine | 2 Memorial Dr Ste 101, Decatur, IL 62526 | 2011-03-08 |
| Find all providers in zip 62526 | ||||
| Taxonomy Code | 261QF0400X |
| Grouping | Ambulatory Health Care Facilities |
| Classification | Clinic/Center |
| Specialization | Federally Qualified Health Center (FQHC) |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1548763238 | Community Health Improvement Center | Clinic/Center | 1027 N Water, Decatur, IL 62523 | 2018-03-09 |
| 1831635770 | Community Health Improvement Center | Clinic/Center | 1027 N Water St, Decatur, IL 62523-1022 | 2017-01-17 |
| 1467784090 | Community Health Improvement Center | Clinic/Center | 1221 East Condit Street, Decatur, IL 62521 | 2010-02-08 |
| 1083884852 | Community Health Improvement Center | Clinic/Center | 243 West Cerro Gordo Street, Decatur, IL 62526 | 2008-03-07 |
| 1790821023 | Oakhurst Medical Centers, Inc. | Clinic/Center | 1760 Candler Rd, Decatur, GA 30032-3254 | 2007-01-30 |
| 1609948306 | Southern Rural Health Care Consortium, Inc. | Clinic/Center | 1304 13th Avenue S.e., Suite F, Decatur, AL 35601 | 2006-11-15 |
| 1053769273 | Recovery Consultants of Atlanta, Inc. | Clinic/Center | 4229 Snapfinger Woods Dr, Decatur, GA 30035-3440 | 2016-05-27 |
| 1114393543 | Saint Joseph's Mercy Care Services Inc. | Clinic/Center | 3110 Clifton Springs Rd, Suite B, Decatur, GA 30034-4600 | 2015-08-20 |
| 1861893216 | Saint Joseph's Mercy Care Services, Inc. | Clinic/Center | 445 Winn Way, Decatur, GA 30030-1707 | 2014-09-04 |
| 1518384213 | Community Health Improvement Center | Clinic/Center | 2300 N Edward St, Decatur, IL 62526-4163 | 2014-03-20 |
| Find all providers in DECATUR | ||||
Please comment or provide details below to improve the information on BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY.
| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.