Board of Trustees of Southern Illinois University
NPI 1104230168 · Clinic/Center · East Saint Louis, IL
Enrolled with Medicare as Part B Supplier - Clinic/Group Practice · source: CMS PECOS Public Provider Enrollment (2026.04.01)
Provider details
- NPI number
- 1104230168
- Entity type
- Organization
- Primary specialty
- Clinic/CenterAmbulatory Health Care Facilities
- Organization subpart
- No
- Authorized official
- Myjal Garner, Director(618) 482-6959
Specialties & taxonomies
Ambulatory Health Care Facilities
- Nurse Practitioner363L00000X
Physician Assistants & Advanced Practice Nursing Providers
Profile Score
A profile completeness & documented-activity index — NOT a quality, outcomes, or patient-satisfaction rating.
- Registry tenure38% of score
12 yrs in NPPES registry
- Profile completeness38% of score
100% of core fields populated
- Practice footprint23% of score
1 documented practice location
Signals a provider has no public data for (e.g. Medicare claims) are left out of the score entirely — never counted as zero — so providers without that data are not penalized. See the full formula and weights in our methodology.
Practice location
Mailing address
Other names (DBA / former)
- Doing business as
- Southern Illinois University Edwardsville
Registry dates
- Enumerated
- 2014-06-18
- Last updated
- 2026-06-07
- Certified
- 2026-06-07
Source: CMS NPPES Data Dissemination (June 2026). NPI Central is not affiliated with CMS. Data is provided as-is from the public registry.