NPIMap

Organization Active NPI

Southern Illinois Healthcare Foundation, Inc.

  • Federally Qualified Health Center (FQHC)
  • Charleston, IL
National Provider Identifier
1487070835
Registry record updated Jun 2, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Practice address
626 W Lincoln Ave
Charleston, IL 61920-2444
Phone
(217) 345-7702
Fax
(217) 345-7705
NPI assigned
Mar 10, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 2, 2016

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

Authorized official

Name
Larry McCulley
Title
Ceo
Phone
(618) 332-0694

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X
DentistGroup: 193200000X MULTI-SPECIALTY GROUP 122300000X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

626 W Lincoln Ave
Charleston, IL 61920-2444

Mailing address

2041 Goose Lake Rd
Sauget, IL 62206-2822
Phone (618) 332-0953

Other names 1

  • Charleston 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
O20031126000641 IL Part B Supplier - Clinic/Group Practice 1456256874 Receives reassigned benefits from 170 practitioners
This NPI is an additional NPI on the enrollment
Practice locations: East Saint Louis, IL; Effingham, IL; Fairmont City, IL; Glen Carbon, IL; Granite City, IL; Greenup, IL; Mattoon, IL; Millstadt, IL…
O20140422000002 IL Part A Provider - Federally Qualified Health Center (FQHC) 1456256874 Practice locations: Charleston, IL

Federally qualified health center certification: CCN 781814

Legal name
SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 14, 2014
Last certification
Apr 14, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 27, 1985 in IL
Enrollment address
626 W Lincoln Ave
Charleston, IL 61920-2444

National Provider Directory

National Provider Directory
Tax ID family
Southern Illinois Hthca38 organizations share this tax ID, including this one

Other organizations with this tax ID 37

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

View all 37

Ownership & related parties

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.

NameRoleSinceShare
Percy McKinney Individual Corporate DirectorBoard Member Apr 22, 2024
Walter Hunter Individual Corporate OfficerVice Chairperson Mar 1, 2008
Gerard Hasenstab Individual Corporate DirectorBoard Member Jan 1, 2019
Dale Fiedler Individual Corporate DirectorBoard Member Jan 1, 2020
Debra Reed Individual Corporate DirectorBoard Member Jan 1, 2021
Larry W McCulley Individual Corporate DirectorChief Executive Officer Apr 1, 2010
Kenneth Hall Individual Corporate DirectorBoard Member Apr 1, 2015
Zoila Marty Individual Corporate DirectorBoard Member Sep 1, 2005
Ethel Manager Individual Corporate OfficerChairperson May 1, 1996
Crysten Calvert Individual Corporate OfficerVice Chairperson Jan 1, 2023
Daniel Winkle Individual W-2 Managing EmployeeAd; May 1, 2025
Anna Marie Nelson Individual Corporate DirectorBoard Member Jan 1, 2010
Richard Sinclair Individual Corporate DirectorBoard Member Aug 1, 2006
Darrel Sterling Individual Corporate DirectorBoard Member Jan 1, 2023
Irma Golliday Individual Corporate DirectorBoard Member Aug 1, 1999

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Touchette Regional Hospital IncCahokia Heights, IL, CCN 140077 Hospital Operational/Managerial Control Jun 30, 2009
Touchette Regional Hospital IncCahokia Heights, IL, CCN 14S077 Hospital Operational/Managerial Control Jun 30, 2009

Practitioners & affiliated clinicians

Practitioners 9

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

NPI Registry JSON

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

{
    "created_epoch": "1394409600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1464825600000",
    "number": "1487070835",
    "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": "626 W LINCOLN AVE",
            "city": "CHARLESTON",
            "state": "IL",
            "postal_code": "619202444",
            "telephone_number": "217-345-7702",
            "fax_number": "217-345-7705"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-03-10",
        "last_updated": "2016-06-02",
        "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"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "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": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "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": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Charleston Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Charleston, IL

Sources for this page

Verify at the official NPI Registry.