NPIMap

Organization Active NPI

Board of Trustees of Southern Illinois University

Doing business as Siu Quincy Family Medicine

  • Federally Qualified Health Center (FQHC)
  • Quincy, IL
National Provider Identifier
1376921924
Registry record updated Jan 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Doing business as
Siu Quincy Family Medicine
Practice address
612 N 11TH St
Quincy, IL 62301-2662
Phone
(217) 224-9484
Fax
(217) 224-7950
NPI assigned
May 15, 2015
Last updated
Jan 9, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITYAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 9, 2025

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

Authorized official

Name
Iris Wesley
Title
Ceo
Phone
(217) 757-8000

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Primary Care Clinic/Center 261QP2300X NU

Addresses

Primary practice location

612 N 11TH St
Quincy, IL 62301-2662

Mailing address

PO Box 19639
Springfield, IL 62794-9639
Phone (217) 545-8000

Other names 1

  • SIU QUINCY FAMILY MEDICINE Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130424001019 IL Part B Supplier - Clinic/Group Practice 4486667888 Receives reassigned benefits from 288 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Taylorville, IL; Springfield, IL; Quincy, IL; Pittsfield, IL; Lincoln, IL; Jacksonville, IL; Decatur, IL; Carbondale, IL
O20150831000048 IL Part A Provider - Federally Qualified Health Center (FQHC) 4486667888 Practice locations: Quincy, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1376921924. Details of each certification follow.

Federally qualified health center certification: CCN 781837

Legal name
BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Doing business as
SIU QUINCY FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 15, 2015
Last certification
Sep 15, 2015
Ownership / control type
For profit – partnership
Organization structure
OtherNon-profit
Incorporated
Oct 1, 2012 in IL
Enrollment address
612 N 11TH St
Quincy, IL 62301-2662

Other NPIs with the same Medicare PAC ID 18

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

View all 18

Other NPIs on the same Medicare enrollment 3

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

National Provider Directory

National Provider Directory
Part of
S a Torgerson MD

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

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
Nancy S Zimmers Individual Corporate DirectorBoard Member Jan 1, 2015
Michal Dynda Individual W-2 Managing EmployeeCmo Jan 1, 2015
Iris E Wesley Individual Corporate OfficerCeo Jan 1, 2015
Corporate DirectorFQHC Director Jan 1, 2015
W-2 Managing EmployeeCeo & Director Jan 1, 2015 100%
Drusilla P Lobmaster Individual Corporate DirectorBoard Member Jan 1, 2015
Keith Edward Rechner Individual Corporate Director Jul 1, 2015
Veatrice G Crawford Individual Corporate DirectorBoard Member Jan 1, 2015
Stuart H Shiffman Individual Corporate DirectorBoard Member Jan 1, 2015
Board of Trustees of Southern Illinois University Organization, Quincy, IL Operational/Managerial Control Jun 8, 2012 100%
Jan R Gambach Individual Corporate DirectorBoard Member Jan 1, 2015
Julie Kappes Individual Corporate Director Apr 1, 2017
Zevernett Holloway Individual Corporate Director Apr 1, 2017
Stephanie K Standish Individual Corporate DirectorBoard Members Jan 1, 2015
Marcheta Hays Individual Corporate Director Jul 1, 2017
Waverly Robinson Individual Corporate Director Feb 1, 2022

Owners & managing parties with NPI records 19

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

View all 19

All facility ownership & control disclosures 11

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

FacilityTypeRoleSince
Siu Center for Family MedicineSpringfield, IL, CCN 141168 Federally qualified health center Operational/Managerial Control (100%) Jun 8, 2012
Siu Center for Family Medicine - LincolnLincoln, IL, CCN 781871 Federally qualified health center Operational/Managerial Control (100%) Oct 1, 2012
Board of Trustees of Southern Illinois UniversityDecatur, IL, CCN 781876 Federally qualified health center Operational/Managerial Control Oct 1, 2012
Siu Center for Family Medicine - IwcSpringfield, IL, CCN 781897 Federally qualified health center Operational/Managerial Control (100%) Aug 1, 2017
Siu Center for Family Medicine-Transitions of Western IllinoisQuincy, IL, CCN 781904 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Apr 2, 2018
Apr 2, 2018
Siu Center for Family Medicine - CarbondaleCarbondale, IL, CCN 781933 Federally qualified health center Operational/Managerial Control (100%) Oct 1, 2012
Siu Center for Family Medicine-TaylorvilleTaylorville, IL, CCN 781937 Federally qualified health center Operational/Managerial Control (100%) Mar 10, 2020
Board of Trustees of Southern Illinois UniversityPittsfield, IL, CCN 781942 Federally qualified health center Other (100%) Oct 1, 2012
Siu Center for Family Medicine-JacksonvilleJacksonville, IL, CCN 781066 Federally qualified health center Operational/Managerial Control Oct 1, 2012
Siu Center for Healthy Aging and WellnessSpringfield, IL, CCN 141809 Federally qualified health center Operational/Managerial Control Oct 1, 2012
Siu Center for Family Medicine - Sangamon County HealthSpringfield, IL, CCN 781147 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2012
Oct 1, 2012

Owned or controlled facilities with NPI records 11

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 10

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 23

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.

View all 23

NPI Registry JSON

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

{
    "created_epoch": "1431648000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1736380800000",
    "number": "1376921924",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 19639",
            "city": "SPRINGFIELD",
            "state": "IL",
            "postal_code": "627949639",
            "telephone_number": "217-545-8000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "612 N 11TH ST",
            "city": "QUINCY",
            "state": "IL",
            "postal_code": "623012662",
            "telephone_number": "217-224-9484",
            "fax_number": "217-224-7950"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY",
        "enumeration_date": "2015-05-15",
        "last_updated": "2025-01-09",
        "certification_date": "2025-01-09",
        "status": "A",
        "authorized_official_last_name": "WESLEY",
        "authorized_official_first_name": "IRIS",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "217-757-8000"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SIU QUINCY FAMILY MEDICINE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Quincy, IL

Sources for this page

Verify at the official NPI Registry.