NPIMap

Organization Active NPI

Board of Trustees of Southern Illinois University

  • Federally Qualified Health Center (FQHC)
  • Springfield, IL
National Provider Identifier
1558099523
Registry record updated Aug 9, 2022
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
Practice address
747 N Rutledge St Ste 2287-B
Springfield, IL 62702-6700
Phone
(217) 545-8000
NPI assigned
Aug 9, 2022
Organization subpart
Yes
Parent organization
BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITYAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 9, 2022

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) 757-8137

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

747 N Rutledge St Ste 2287-B
Springfield, IL 62702-6700

Mailing address

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

Other names 1

  • SIU FQHC - General Internal Medicine Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20221104000252 IL Part A Provider - Federally Qualified Health Center (FQHC) 4486667888 Practice locations: Springfield, IL

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

Federally qualified health center certification: CCN 781082

Legal name
BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Doing business as
SIU FQHC - GENERAL INTERNAL MEDICINE CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 2, 2022
Last certification
Nov 2, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 1, 2012 in IL
Enrollment address
747 N Rutledge St
Ste 2287-B
Springfield, IL 62702-6700

National Provider Directory

National Provider Directory
Tax ID family
DRS Herald and Thompson29 organizations share this tax ID, including this one
Part of
DRS Herald and Thompson

Other organizations with this tax ID 28

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

View all 28

Locations

747 N Rutledge St
Ste 2287B
Springfield, IL 62702

Ownership & related parties

All disclosed owners & managing parties 12

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 Jan 1, 2014
Iris E Wesley Individual Corporate Director Jul 1, 2012
Operational/Managerial Control Jul 1, 2021
Drusilla P Lobmaster Individual Corporate Director Jul 1, 2015
Keith Edward Rechner Individual Corporate Director Jul 1, 2015
Veatrice G Crawford Individual Corporate Director Jul 1, 2012
Stuart H Shiffman Individual Corporate Director Jan 1, 2014
Jan R Gambach Individual Corporate Director Jul 1, 2012
Julie Kappes Individual Corporate Director Apr 1, 2017
Zevernett Holloway Individual Corporate Director Apr 1, 2017
Stephanie K Standish Individual Corporate Director Jul 1, 2012
Marcheta Hays Individual Corporate Director Jul 1, 2017
Waverly Robinson Individual Corporate Director Feb 1, 2022

All facility ownership & control disclosures 12

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
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 12

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

Practitioners 139

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

View all 139

NPI Registry JSON

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

{
    "created_epoch": "1660003200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1660003200000",
    "number": "1558099523",
    "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": "747 N RUTLEDGE ST STE 2287-B",
            "city": "SPRINGFIELD",
            "state": "IL",
            "postal_code": "627026700",
            "telephone_number": "217-545-8000"
        }
    ],
    "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": "2022-08-09",
        "last_updated": "2022-08-09",
        "certification_date": "2022-08-03",
        "status": "A",
        "authorized_official_last_name": "WESLEY",
        "authorized_official_first_name": "IRIS",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "217-757-8137"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SIU FQHC - General Internal Medicine Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Springfield, IL

Sources for this page

Verify at the official NPI Registry.