NPIMap

Organization Active NPI

Board of Trustees of Southern Illinois University

  • Federally Qualified Health Center (FQHC)
  • Jacksonville, IL
National Provider Identifier
1649628009
Registry record updated May 26, 2016
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
345 W State St
Jacksonville, IL 62650-1879
Phone
(217) 245-5111
Fax
(217) 243-4773
NPI assigned
May 26, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 26, 2016

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) 545-8000

Specialties & licenses 1

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

Addresses

Primary practice location

345 W State St
Jacksonville, IL 62650-1879

Mailing address

520 N 4TH St
PO Box 19671
Springfield, IL 62702-5238
Phone (217) 545-8000

Other names 1

  • SIU CENTER FOR FAMILY MEDICINE-JACKSONVILLE Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160725001980 IL Part A Provider - Federally Qualified Health Center (FQHC) 4486667888 Practice locations: Jacksonville, IL

Federally qualified health center certification: CCN 781854

Legal name
BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Doing business as
SIU CENTER FOR FAMILY MEDICINE - JACKSONVILLE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 25, 2016
Last certification
Jul 25, 2016
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 1, 2012 in IL
Enrollment address
345 W State St
Jacksonville, IL 62650-1879

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

National Provider Directory

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

Other organizations with this tax ID 28

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

View all 28

Ownership & related parties

All disclosed owners & managing parties 16

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 DirectorBoard Member Jan 1, 2015
Michal Dynda Individual W-2 Managing EmployeeChief Medical Officer Jan 1, 2015
Iris E Wesley Individual Corporate OfficerCeo Jan 1, 2015
Corporate DirectorFQHC Director Jan 1, 2015
W-2 Managing EmployeeCeo & Director Jan 1, 2015
Drusilla P Lobmaster Individual Corporate DirectorBoard Member Jan 1, 2015
Francesca M Abbott Individual Corporate DirectorBoard Member Jan 1, 2015
Keith Edward Rechner Individual Corporate DirectorBoard Member Oct 1, 2015
Veatrice G Crawford Individual Corporate DirectorBoard Member Jan 1, 2015
Stuart H Shiffman Individual Corporate DirectorBoard Member Jan 1, 2015
Jan R Gambach Individual Corporate DirectorBoard Member Jan 1, 2015
Gerald D Suchomski Individual Corporate DirectorBoard Member Jan 1, 2015
Ellen S King-Pietrzak Individual W-2 Managing EmployeeCfo Oct 1, 2015
Burton Bradford Billings Individual Corporate DirectorBoard Member Oct 1, 2015
Stephanie K Standish Individual Corporate DirectorBoard Member Jan 1, 2015
Peter R Cadwell Individual Corporate DirectorBoard Member Jan 1, 2015
Linda a Toth Individual Corporate OfficerAssociate Dean for Research Jan 1, 2015
Silas Johnson Individual Corporate DirectorBoard Member Jan 1, 2015

Owners & managing parties with NPI records 1

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

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 & affiliated clinicians

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": "1464220800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1464220800000",
    "number": "1649628009",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "520 N 4TH ST",
            "address_2": "PO BOX 19671",
            "city": "SPRINGFIELD",
            "state": "IL",
            "postal_code": "627025238",
            "telephone_number": "217-545-8000",
            "fax_number": "217-747-1351"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "345 W STATE ST",
            "city": "JACKSONVILLE",
            "state": "IL",
            "postal_code": "626501879",
            "telephone_number": "217-245-5111",
            "fax_number": "217-243-4773"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-05-26",
        "last_updated": "2016-05-26",
        "status": "A",
        "authorized_official_last_name": "WESLEY",
        "authorized_official_first_name": "IRIS",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "217-545-8000"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "IL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SIU CENTER FOR FAMILY MEDICINE-JACKSONVILLE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jacksonville, IL

Sources for this page

Verify at the official NPI Registry.