Shawnee Health Service and Development Corp
Organization Active NPI Federally Qualified Health Center (FQHC) · Marion, IL
NPI 1114631967 · NPPES record last updated Jul 29, 2024
Key facts
- NPI
- 1114631967
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
- Practice address
- 700 E Boulevard St
Marion, IL 62959-3306 - Phone
- (618) 519-9200
- Fax
- (618) 998-0880
- NPI assigned
- Jan 6, 2023
- Organization subpart
- Yes
- Parent organization (as reported)
- SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Authorized official
- Name
- Christina Carney
- Title
- Ceo
- Phone
- (618) 956-9521
Other NPIs on the same Medicare enrollment 20
Other NPIs with the same Medicare PAC ID 21
Corporate family (same tax ID) 35
Practitioners 51
-
Molly Cook, LCSW
-
Samantha Herrin, PA-C
-
Jessica N Baine, APRN
-
Amanda J Bowers, FNP
-
Haley Brinkley, APRN
-
Ruthann Coale, APRN
-
Nicole Davis, MS, RDN, LDN
-
Linda Dodd, PMHNP-BC
-
Amanda Ellis, LCPC
-
Cheryl Ellis, APN
-
Lindsey Falmier, LCSW
-
Kara Danielle Flatt, APN
-
Tasmeer Hassan, MD
-
Rachael O Johnson, PMHNP-BC
-
Teresa Johnson, APRN
-
Sherry K Jones, MD
-
Ruth Karnes, LCSW
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in IL
Federally qualified health center certification: CCN C41009
- Legal name
- SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
- Doing business as
- JEFFERSON ELEMENTARY SCHOOL HEALTH CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Sep 14, 2023
- Last certification
- Sep 14, 2023
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- May 2, 1972 in IL
- Enrollment address
- 700 E Boulevard St
RM C23
Marion, IL 62959-3306
All disclosed owners & managing parties 14
| Name | Role | Since | Share |
|---|---|---|---|
| Kevin Lipe |
Corporate Director |
Feb 4, 2021 | |
| Carolin Harvey |
Corporate Director |
Aug 5, 2021 | |
| Leigh Ann Hacker |
W-2 Managing Employee |
Sep 27, 2018 | |
| George Marin |
Corporate Director |
Jun 2, 2022 | |
| Jeffrey Cooper |
Corporate Officer |
Jul 1, 2008 | |
| W-2 Managing Employee |
Jul 1, 2008 | ||
| Julian Valdes |
Corporate Director |
May 5, 2022 | |
| Dale Ritzel |
Corporate Director |
Mar 7, 2013 | |
| Teresa Wisely |
W-2 Managing Employee |
Jun 1, 2022 | |
| Jose Llamas |
Corporate Director |
Oct 3, 2019 | |
| Arun Subramanian |
Corporate Director |
Oct 1, 2015 | |
| Kelley Hessian |
Corporate Director |
Jul 17, 1989 | |
| Christina Carney |
Corporate Director | Aug 31, 2023 | |
| Susan Murray |
Corporate Director |
Jul 6, 2017 | |
| Shane Carsrud |
Corporate Director |
Oct 7, 2021 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
| O20230919002401 | IL | Part a Provider - Federally Qualified Health Center (FQHC) | 1658285671 | Practice locations: Marion, IL |
National Provider Directory
- Tax ID family
- Grand Tower Health Cent
- Part of
- Grand Tower Health Cent
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor |
101YM0800X | |||
| Clinical Social Worker |
1041C0700X | |||
| General Practice Dentistry |
1223G0001X | |||
| Dental Hygienist |
124Q00000X | |||
| Family Medicine Physician |
207Q00000X | |||
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
700 E Boulevard St
Marion, IL 62959-3306
Mailing address
109 California St
PO Box 577
Carterville, IL 62918
Phone (618) 519-9200
Other names
- Jefferson Elementary School Health Center
Other providers in Marion, IL
- Senior Med Services Inc
- Meghan Jo Shackleton
- Donna S Shadowens
- Kalinda Jo Shaw
- Shawnee Health Service and Development Corp
- Shawnee Health Service and Development Corp
- Shawnee Health Service and Development Corp
- Shawnee Health Service and Development Corp
- Shawnee Health Service and Development Corp
- Shawnee Health Service and Development Corp
All providers in Marion, IL · Federally Qualified Health Center (FQHC) in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 29, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.