Southern Illinois Healthcare Foundation, Inc.

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

Legal business name

SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.

Practice address

2900 Frank Scott Pkwy W
Suite 950
Belleville, IL 62223-5000

Phone

(618) 233-3205

Fax

(618) 233-1407

NPI assigned

Jun 18, 2006

Organization subpart

No

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

Authorized official

Name

Mr. Larry McCulley

Title

Ceo

Phone

(618) 332-0694

Specialties & licenses 4

Addresses

Other identifiers 1

Other names 1

• Belleville Pediatric & Adolescent Health Center Doing business as

Medicare fee-for-service enrollment

Enrolled in IL2 enrollments

Enrollment records 2

Federally qualified health center certification: CCN 781823

Legal name

SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Aug 28, 2014

Last certification

Aug 28, 2014

Ownership / control type

For profit – corporation

Organization structure

CorporationNon-profit

Enrollment address

2900 Frank Scott Pkwy W
Ste 950
Belleville, IL 62223-5010

Locations

All disclosed owners & managing parties 15

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

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Rebecca A Ashworth-Rhein, LCSW

  • Clinical Social Worker
  • Belleville, IL
  • NPI 1699178863
  NPD
• Kelsey M Beard, FNP-BC, DNP

  • Family Nurse Practitioner
  • Alton, IL
  • NPI 1124612445
  NPD
• Marjorie H. Guthrie, M.D.

  • Family Medicine Physician
  • O Fallon, IL
  • NPI 1366490146
  NPD
• Kelly Ruth Hall, NP-C

  • Family Nurse Practitioner
  • Sandoval, IL
  • NPI 1912553892
  NPD
• Yolanda L Hoag, ACNPC-AG

  • Acute Care Nurse Practitioner
  • East Saint Louis, IL
  • NPI 1053815423
  NPD
• Tierra Q Smith, FNP-BC

  • Family Nurse Practitioner
  • East Saint Louis, IL
  • NPI 1316647753
  NPD
• Sydney P Stevens, PA-C

  • Medical Physician Assistant
  • Belleville, IL
  • NPI 1740879493
  NPD
• Christopher Dean Suhre, MD

  • Pediatrics Physician
  • East Alton, IL
  • NPI 1255350252
  NPD
• Roy Marshall Wagner, DO

  • Family Medicine Physician
  • O Fallon, IL
  • NPI 1477187383
  NPD
• Jeremy C Hollingsead, FNP

  • Family Nurse Practitioner
  • Roseburg, OR
  • NPI 1376000232
  NPD

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

{
    "created_epoch": "1150588800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1407456000000",
    "number": "1376588871",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2041 GOOSE LAKE RD",
            "city": "SAUGET",
            "state": "IL",
            "postal_code": "622062822",
            "telephone_number": "618-332-0953",
            "fax_number": "618-332-2487"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2900 FRANK SCOTT PKWY W",
            "address_2": "SUITE 950",
            "city": "BELLEVILLE",
            "state": "IL",
            "postal_code": "622235000",
            "telephone_number": "618-233-3205",
            "fax_number": "618-233-1407"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-18",
        "last_updated": "2014-08-08",
        "status": "A",
        "authorized_official_last_name": "MCCULLEY",
        "authorized_official_first_name": "LARRY",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "618-332-0694",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WPS MEDICARE",
            "identifier": "732740",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Belleville Pediatric & Adolescent Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Southern Illinois Healthcare Foundation Inc
• Southern Illinois Healthcare Foundation Inc
• Southern Illinois Healthcare Foundation, Inc
• Southern Illinois Healthcare Foundation, Inc.
• Southern Illinois Healthcare Foundation, Inc.
• Southern Illinois Healthcare Foundation, Inc.
• Southern Illinois Healthcare Foundation, Inc.
• Southern Illinois Internal Medicine LTD
• Southern Illinois Neurologic Institute
• Southern Illinois Oral & Maxillofacial Surgery, LTD.

• Federally Qualified Health Center (FQHC) in Belleville, IL
• Providers in Belleville, IL by specialty
• Federally Qualified Health Center (FQHC) in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 8, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.