Mendota Community Hospital
Organization Active NPI Family Medicine Physician · Mendota, IL
NPI 1407872997 · NPPES record last updated Mar 18, 2024
Key facts
- NPI
- 1407872997
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 0001537 (IL)
- Legal business name
- MENDOTA COMMUNITY HOSPITAL
- Practice address
- 1401 East 12TH Street
Mendota, IL 61342-9216 - Phone
- (815) 539-7461
- Fax
- (815) 538-5516
- NPI assigned
- Jul 15, 2006
- Organization subpart
- No
Authorized official
- Name
- Robert C. Sehring
- Title
- Ceo, Osf Healthcare System
- Phone
- (306) 655-2850
Owners & managing parties with NPI records 1
Other NPIs on the same Medicare enrollment 3
Other NPIs with the same Medicare PAC ID 8
Related certifications (CCN) 1
Practitioners 105
-
Shawn E Bailey, MD
-
Jamie Bond, FNP
-
Ricardo Joseph Calderon, M.D.
-
Keith Christensen, APN, FNP
-
Maddalena Davenport, APRN
-
Karen L Eggers, FNP-BC
-
Kara O Fess, MD
-
Angella Marie Greenwood, APN, FNP, BC
-
Gueorgui S Gueorguiev, M.D.
-
Lisa Kay Gustafson, MS/LCPC
-
Debra Herz, FNP-BC
-
Fazal Khan, M.D.
-
Hallie Konieczki, APN
-
Kellie Marie Kozlowski, PMHNP-BC
-
Marcela Renee Lemus, FNP-C
-
Britnae L Lewis, APRN, CNP
-
Leonardo Lopez, M.D.
-
Louis R Lukancic, MD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in IL
Rural health clinic certification: CCN 148535
- Legal name
- MENDOTA COMMUNITY HOSPITAL
- Doing business as
- OSF HEALTHCARE - MEDICAL GROUP - MENDOTA
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Feb 11, 2015
- Last certification
- Feb 11, 2015
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jan 1, 1965 in IL
- Enrollment address
- 1405 E 12TH St, Ste 300, 600
Mendota, IL 61342-9010 - Related CCNs
- 141310
All disclosed owners & managing parties 16
| Name | Role | Since | Share |
|---|---|---|---|
| Patricia a Brazeau |
Corporate Officer | Oct 1, 2006 | |
| Corporate Director | Oct 1, 2006 | ||
| Dawn C Trompeter |
Contracted Managing Employee |
Jan 1, 2019 | |
| Operational/Managerial Control |
Jan 1, 2019 | ||
| Anne M Ziegler |
Corporate Director | Jul 1, 2021 | |
| Melanie R Mann |
Corporate Officer | Oct 6, 2024 | |
| Corporate Director | Oct 1, 2006 | ||
| Gerald J McShane |
Corporate Director | Sep 1, 1996 | |
| Osf Healthcare Ministries |
Operational/Managerial Control | Nov 1, 2024 | |
| Michelle a Carrothers |
Operational/Managerial Control |
Feb 1, 2018 | |
| Kathleen F Williams |
Corporate Officer | Nov 1, 2014 | |
| Corporate Director | Jan 1, 2003 | ||
| Kirsten M Largent |
Contracted Managing Employee |
Nov 8, 2024 | |
| Corporate Officer | Nov 8, 2024 | ||
| Operational/Managerial Control | Nov 8, 2024 | ||
| Osf Healthcare System |
Operational/Managerial Control | Apr 1, 2015 | |
| Robert C Sehring |
Contracted Managing Employee |
Oct 20, 2017 | |
| Corporate Officer | Oct 20, 2017 | ||
| Corporate Director | Oct 20, 2017 | ||
| Operational/Managerial Control | Oct 20, 2017 | ||
| Judith a Duvall |
Corporate Officer | Oct 1, 2006 | |
| Corporate Director | Oct 1, 1989 | ||
| Carisa a Neumann |
Corporate Director | Jul 1, 2021 | |
| Brian J Silverstein |
Corporate Director | Jan 27, 2014 | |
| Paula K Selamat |
Corporate Director | Oct 6, 2024 | |
| Bridget J Meidl |
Corporate Director | Nov 1, 2014 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040131000102 | IL | Part B Supplier - Clinic/Group Practice | 2264335777 |
Receives reassigned benefits from 104 practitioners 2 other NPIs on this enrollment Practice locations: Oglesby, IL; Paw Paw, IL; Peru, IL; Spring Valley, IL; Mendota, IL; Granville, IL |
| O20140619002050 | IL | Part a Provider - Rural Health Clinic | 2264335777 |
1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Mendota, IL |
National Provider Directory
Locations
1436 Midtown Rd
Peru, IL 61354
Phone (815) 220-3111
1650 Midtown Rd
Peru, IL 61354
Phone (815) 220-1122
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | 0001537 | IL | Yes |
| Orthopaedic Surgery Physician |
207X00000X | 0001537 | IL | |
| Surgery Physician |
208600000X | 0001537 | IL | |
| Physician Assistant |
363A00000X | 0001537 | IL | |
| Nurse Practitioner |
363L00000X | 0001537 | IL |
Addresses
Primary practice location
1401 East 12TH Street
Mendota, IL 61342-9216
Mailing address
124 SW Adams St
Peoria, IL 61602-1320
Phone (093) 655-2850
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| CI2549 | Other | RAILROAD MEDICARE |
Other names
- OSF Medical Group-Mendota
- Physician Services of MCH
Other providers in Mendota, IL
- Mendota C C School Dist 289
- Mendota Community Hospital
- Mendota Community Hospital
- Mendota Community Hospital
- Mendota Community Hospital
- Mendota Community Hospital
- Mendota Community Hospital
- Mendota Community Hospital
- Mendota Community Hospital
- Mendota Community Hospital
All providers in Mendota, IL · Family Medicine Physician in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 18, 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.