NPIMap

Organization Active NPI

Shawnee Health Service and Development Corp

Doing business as Shawnee Health Social Services

  • Federally Qualified Health Center (FQHC)
  • Carterville, IL
National Provider Identifier
1053002907
Registry record updated Jul 16, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Doing business as
Shawnee Health Social Services
Practice address
6355 Brandhorst Rd
Carterville, IL 62918-3322
Phone
(618) 519-9200
Fax
(618) 985-9096
NPI assigned
May 19, 2023
Last updated
Jul 16, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORPAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 16, 2024

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

Authorized official

Name
Christina Carney
Title
Ceo
Phone
(618) 956-9521

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health Counselor 101YM0800X NU
Clinical Social Worker 1041C0700X NU
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

6355 Brandhorst Rd
Carterville, IL 62918-3322

Mailing address

PO Box 577
Carterville, IL 62918-0577
Phone (618) 985-8221

Other names 1

  • Shawnee Health Social Services Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031120000454 IL Part B Supplier - Clinic/Group Practice 1658285671 Receives reassigned benefits from 54 practitioners
28 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Carterville, IL; Murphysboro, IL; Marion, IL; Herrin, IL; Carbondale, IL
O20230802000606 IL Part A Provider - Federally Qualified Health Center (FQHC) 1658285671 Practice locations: Carterville, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1053002907. Details of each certification follow.

Federally qualified health center certification: CCN 781957

Legal name
SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Doing business as
SHAWNEE HEALTH SOCIAL SERVICES
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 20, 2023
Last certification
Jun 20, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 2, 1972 in IL
Enrollment address
6355 Brandhorst Rd
Carterville, IL 62918-3322

Other NPIs with the same Medicare PAC ID 21

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 21

Other NPIs on the same Medicare enrollment 20

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 20

National Provider Directory

National Provider Directory
Tax ID family
Grand Tower Comm HLTH C37 organizations share this tax ID, including this one
Part of
Grand Tower Comm HLTH C

Other organizations with this tax ID 36

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

View all 36

Ownership & related parties

All disclosed owners & managing parties 14

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Kevin Lipe Individual Corporate DirectorBoard Member Feb 4, 2021
Carolin Harvey Individual Corporate DirectorBoard Member Aug 5, 2021
Leigh Ann Hacker Individual W-2 Managing EmployeeCredentialing Specialist Sep 27, 2018
OtherCredentialing Specialist Sep 27, 2018
George Marin Individual Corporate DirectorBoard Member Jun 2, 2022
Jeffrey Cooper Individual Corporate OfficerChief Financial Officer Jul 1, 2008
W-2 Managing EmployeeChief Financial Officer Jul 1, 2008
Julian Valdes Individual Corporate DirectorBoard Member May 5, 2022
Dale Ritzel Individual Corporate DirectorBoard Vice President Mar 7, 2013
Teresa Wisely Individual W-2 Managing EmployeeCredentialing Specialist Jun 1, 2022
Jose Llamas Individual Corporate DirectorBoard Member Oct 3, 2019
Arun Subramanian Individual Corporate DirectorBoard Member Oct 1, 2015
Kelley Hessian Individual Corporate DirectorBoard Member Jul 17, 1989
Christina Carney Individual Corporate OfficerChief Executive Officer Aug 1, 2023
W-2 Managing EmployeeChief Executive Officer Aug 1, 2023
Susan Murray Individual Corporate DirectorBoard Member Jul 6, 2017
Shane Carsrud Individual Corporate DirectorBoard Secretary/Treasurer Oct 7, 2021

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1684454400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1721088000000",
    "number": "1053002907",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 577",
            "city": "CARTERVILLE",
            "state": "IL",
            "postal_code": "629180577",
            "telephone_number": "618-985-8221",
            "fax_number": "618-985-6860"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6355 BRANDHORST RD",
            "city": "CARTERVILLE",
            "state": "IL",
            "postal_code": "629183322",
            "telephone_number": "618-519-9200",
            "fax_number": "618-985-9096"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP",
        "enumeration_date": "2023-05-19",
        "last_updated": "2024-07-16",
        "certification_date": "2024-07-16",
        "status": "A",
        "authorized_official_last_name": "CARNEY",
        "authorized_official_first_name": "CHRISTINA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "618-956-9521"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shawnee Health Social Services",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Shawnee Health Social Services",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Carterville, IL

Sources for this page

Verify at the official NPI Registry.