NPIMap

Organization Active NPI

Memorial Physician Services

  • Rural Health Clinic/Center
  • Jacksonville, IL
National Provider Identifier
1558614867
Registry record updated Feb 11, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MEMORIAL PHYSICIAN SERVICES
Practice address
15 Founders LN
Suite 100
Jacksonville, IL 62650-3919
Phone
(217) 243-0300
Fax
(217) 245-6775
NPI assigned
Oct 24, 2012
Last updated
Feb 11, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 11, 2021

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

Authorized official

Name
James T Dowell
Title
Vice President, MPS
Phone
(217) 788-3342

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

15 Founders LN
Suite 100
Jacksonville, IL 62650-3919

Mailing address

PO Box 3428
Springfield, IL 62708-3428
Phone (800) 577-5368

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130125000152 IL Part A Provider - Rural Health Clinic 9032005681 Practice locations: Jacksonville, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1558614867. Details of each certification follow.

Rural health clinic certification: CCN 148905

Legal name
MEMORIAL PHYSICIAN SERVICES
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 24, 1999
Last certification
May 6, 2026
Ownership / control type
2B
Most recent change of ownership
Jan 1, 2013 (2 total)
Organization structure
CorporationNon-profit
Incorporated
Apr 7, 1997 in IL
Enrollment address
15 Founders Lane
Suite 100
Jacksonville, IL 62650-3924

Other NPIs with the same Medicare PAC ID 5

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

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
14D1088575Memorial Physician Services - Jacksonville15 Founders Lane, Ste 100, Jacksonville, IL 62650Certificate of waiverAug 27, 2026

National Provider Directory

National Provider Directory
Tax ID family
Memorial Physician Services12 organizations share this tax ID, including this one

Other organizations with this tax ID 11

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

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
Christina L Scheibler-Ventress Individual Corporate OfficerMD Jan 12, 2023
Corporate DirectorMD Jan 12, 2023
David B Sandercock Individual Corporate OfficerMD Jan 10, 2024
Corporate DirectorMD Jan 10, 2024
Mandy C. Eaton Individual Corporate DirectorPresident & Ceo MH Apr 1, 2025
Nathan Pyle Individual Corporate OfficerDO Jan 12, 2023
Corporate DirectorDO Jan 12, 2023
Jameson Roszhart Individual Corporate OfficerPresident & Ceo Jul 1, 2024
Corporate DirectorPresident & Ceo Jul 1, 2024
W-2 Managing Employee Jun 15, 2009
Kimberly R Beggs Individual Corporate OfficerPresident & Ceo MPS Jul 1, 2024
W-2 Managing Employee Dec 18, 2000
Memorial Health System Organization, Springfield, IL Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 1997
Drew Early Individual Corporate OfficerPresident & Ceo DMH Jan 10, 2024
Corporate DirectorPresident & Ceo DMH Jan 10, 2024
Anthony M Griffin Individual Corporate OfficerMD Jan 10, 2018
Corporate DirectorMD Jan 10, 2018
Judi Harlan Individual W-2 Managing Employee Mar 1, 2020
Kathryn J Keim Individual Corporate OfficerVP & Cfo Jan 1, 2019
Amir J Wahab Individual Corporate OfficerMD Sep 8, 2021
Corporate DirectorMD Sep 8, 2021
Ann E Bowling Individual W-2 Managing EmployeeDirector Apr 5, 2010

Owners & managing parties with NPI records 5

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

Facilities with the same owner 13

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

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1351036800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1613001600000",
    "number": "1558614867",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3428",
            "city": "SPRINGFIELD",
            "state": "IL",
            "postal_code": "627083428",
            "telephone_number": "800-577-5368",
            "fax_number": "217-757-2021"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15 FOUNDERS LN",
            "address_2": "SUITE 100",
            "city": "JACKSONVILLE",
            "state": "IL",
            "postal_code": "626503919",
            "telephone_number": "217-243-0300",
            "fax_number": "217-245-6775"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEMORIAL PHYSICIAN SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-24",
        "last_updated": "2021-02-11",
        "certification_date": "2021-02-11",
        "status": "A",
        "authorized_official_last_name": "DOWELL",
        "authorized_official_first_name": "JAMES",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "VICE PRESIDENT, MPS",
        "authorized_official_telephone_number": "217-788-3342"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, IL

Sources for this page

Verify at the official NPI Registry.