NPIMap

Organization Active NPI

Shawnee Health Service and Development Corp

Doing business as Jefferson Elementary School Health Center

  • Federally Qualified Health Center (FQHC)
  • Marion, IL
National Provider Identifier
1114631967
Registry record updated Jul 29, 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
Jefferson Elementary School Health Center
Practice address
700 E Boulevard St
Marion, IL 62959-3306
Phone
(618) 519-9200
Fax
(618) 998-0880
NPI assigned
Jan 6, 2023
Last updated
Jul 29, 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 29, 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 6

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Mental Health Counselor 101YM0800X
Clinical Social Worker 1041C0700X
General Practice Dentistry 1223G0001X
Dental Hygienist 124Q00000X
Family Medicine Physician 207Q00000X

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 1

  • Jefferson Elementary School Health Center 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
O20230919002401 IL Part A Provider - Federally Qualified Health Center (FQHC) 1658285671 Practice locations: Marion, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1114631967. Details of each certification follow.

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
CorporationNon-profit
Incorporated
May 2, 1972 in IL
Enrollment address
700 E Boulevard St
RM C23
Marion, IL 62959-3306

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
Shawnee Health SVC Deve37 organizations share this tax ID, including this one
Part of
Shawnee Health SVC Deve

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
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 DirectorVice 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 Director Aug 31, 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": "1672963200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1722211200000",
    "number": "1114631967",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "109 CALIFORNIA ST",
            "address_2": "PO BOX 577",
            "city": "CARTERVILLE",
            "state": "IL",
            "postal_code": "62918",
            "telephone_number": "618-519-9200",
            "fax_number": "618-985-6860"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "700 E BOULEVARD ST",
            "city": "MARION",
            "state": "IL",
            "postal_code": "629593306",
            "telephone_number": "618-519-9200",
            "fax_number": "618-998-0880"
        }
    ],
    "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": "2023-01-06",
        "last_updated": "2024-07-29",
        "certification_date": "2024-07-29",
        "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": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "124Q00000X",
            "taxonomy_group": "",
            "desc": "Dental Hygienist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jefferson Elementary School Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Jefferson Elementary School Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Marion, IL

Sources for this page

Verify at the official NPI Registry.