NPIMap

Organization Active NPI

Board of Trustees of Southern Illinois University

Doing business as SIU Center for Family Medicine - Decatur

  • Federally Qualified Health Center (FQHC)
  • Decatur, IL
National Provider Identifier
1407376338
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 Center for Family Medicine - Decatur
Practice address
102 W Kenwood Ave
Decatur, IL 62526-4368
Phone
(217) 872-3800
Fax
(217) 872-0849
NPI assigned
Jun 21, 2017
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
Chief Executive Officer
Phone
(217) 545-7876

Specialties & licenses 2

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

Addresses

Primary practice location

102 W Kenwood Ave
Decatur, IL 62526-4368

Mailing address

PO Box 19639
Springfield, IL 62794-9639
Phone (217) 872-3800

Other names 1

  • SIU Center for Family Medicine - Decatur Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170717002084 IL Part A Provider - Federally Qualified Health Center (FQHC) 4486667888 Practice locations: Decatur, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1407376338. Details of each certification follow.

Federally qualified health center certification: CCN 781876

Legal name
BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 17, 2017
Last certification
Jul 17, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 1, 2012 in IL
Enrollment address
102 W Kenwood Ave
Ste 100
Decatur, IL 62526-4379

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D0435205Siu Medicine Decatur102 W Kenwood Ste 100, Decatur, IL 62526Provider-performed microscopyAug 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Susan M Tucker MD29 organizations share this tax ID, including this one
Part of
Susan M Tucker MD

Other organizations with this tax ID 28

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

View all 28

Locations

102 W Kenwood Ave
Decatur, IL 62526
Phone (217) 872-3800

Ownership & related parties

All disclosed owners & managing parties 13

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 Director Jul 1, 2017
Iris E Wesley Individual Corporate DirectorDirector Jul 1, 2017
W-2 Managing EmployeeChief Executive Officer Jul 1, 2017
Operational/Managerial Control Oct 1, 2012
Drusilla P Lobmaster Individual Corporate Director Jul 1, 2017
Keith Edward Rechner Individual Corporate Director Jul 1, 2017
Veatrice G Crawford Individual Corporate Director Jul 1, 2017
Stuart H Shiffman Individual Corporate DirectorDirector Jul 1, 2017
Board of Trustees of Southern Illinois University Organization, Decatur, IL Non-profit Operational/Managerial Control Oct 1, 2012
Jan R Gambach Individual Corporate Director Jul 1, 2012
Julie Kappes Individual Corporate Director Jul 1, 2017
Zevernett Holloway Individual Corporate Director Jul 1, 2017
Stephanie K Standish Individual Corporate Director Jul 1, 2017
Marcheta Hays Individual Corporate Director Jul 1, 2017
Waverly Robinson Individual Corporate Director Apr 1, 2025

Owners & managing parties with NPI records 18

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

View all 18

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 Quincy Family MedicineQuincy, IL, CCN 781837 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
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 6

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": "1498003200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1736380800000",
    "number": "1407376338",
    "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": "217-872-3800",
            "fax_number": "217-872-0849"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "102 W KENWOOD AVE",
            "city": "DECATUR",
            "state": "IL",
            "postal_code": "625264368",
            "telephone_number": "217-872-3800",
            "fax_number": "217-872-0849"
        }
    ],
    "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": "2017-06-21",
        "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": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "217-545-7876"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "IL",
            "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 Center for Family Medicine - Decatur",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Decatur, IL

Sources for this page

Verify at the official NPI Registry.