St Mary Medical Center
Organization Active NPI Rural Health Clinic/Center · Abingdon, IL
NPI 1750006110 · NPPES record last updated Mar 18, 2024
Key facts
- NPI
- 1750006110
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- ST MARY MEDICAL CENTER
- Practice address
- 100 N Monroe St
Abingdon, IL 61410-1457 - Phone
- (309) 462-2342
- Fax
- (309) 655-4878
- NPI assigned
- Oct 7, 2022
- Organization subpart
- Yes
- Parent organization (as reported)
- OSF HEALTHCARE SYSTEM
Authorized official
- Name
- Robert C. Sehring
- Title
- Ceo, Osf Healthcare System
- Phone
- (309) 655-2850
Owners & managing parties with NPI records 2
Other NPIs with the same Medicare PAC ID 7
Corporate family (same tax ID) 11
Related certifications (CCN) 1
Facilities with the same owner 76
Practitioners 52
-
Carolynn R Boatfield, PA-C
-
Kari N. Bruening, NP
-
Deprince Cardenas, APN
-
Annevay Conlee, MD
-
Shannon L Egan, APRN,CNP
-
Heather Godsil, APN
-
Carrie Anne Green, APN
-
Sharie Harden, CNM
-
Renee Elizabeth Hemp, APRN
-
Jeffrey D Hershkowitz, D.O.
-
Michelle L. Johnson, APN
-
Angela B Klapp, APN
-
Korte B Knoblauch, PA-C
-
Yan Liu, MD
-
Jessica L Logan, APRN, CNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 14D0431290 | Osf Healthcare - Medical Group- Abingdon | Certificate of waiver | Sep 10, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
Rural health clinic certification: CCN 148638
- Legal name
- ST MARY MEDICAL CENTER
- Doing business as
- OSF HEALTHCARE - MEDICAL GROUP - ABINGDON
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Mar 2, 2023
- Last certification
- Mar 2, 2023
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Enrollment address
- 100 N Monroe St
Abingdon, IL 61410-1457 - Related CCNs
- 140064
All disclosed owners & managing parties 18
| Name | Role | Since | Share |
|---|---|---|---|
| Patricia a Brazeau |
Corporate Officer | Oct 1, 2006 | |
| Corporate Director | Oct 1, 2006 | ||
| Anne M Ziegler |
Corporate Director | Jan 1, 2021 | |
| Melanie R Mann |
Corporate Officer | Oct 6, 2024 | |
| Corporate Director | Oct 1, 2006 | ||
| August Querciagrossa |
W-2 Managing Employee |
Aug 17, 2022 | |
| Operational/Managerial Control |
Aug 17, 2022 | ||
| Gerald J McShane |
Corporate Director | Sep 1, 1996 | |
| Osf Healthcare Ministries |
Operational/Managerial Control | Nov 1, 2024 | |
| Kathleen F Williams |
Corporate Officer | Nov 1, 2014 | |
| Corporate Director | Jan 1, 2003 | ||
| Kirsten M Largent |
Corporate Officer | Nov 8, 2024 | |
| W-2 Managing Employee |
Nov 8, 2024 | ||
| Operational/Managerial Control |
Nov 8, 2024 | ||
| Lisa M Dekezel |
W-2 Managing Employee |
Nov 18, 2019 | |
| Operational/Managerial Control |
Nov 18, 2019 | ||
| Osf Healthcare System |
Operational/Managerial Control | Jan 1, 1966 | |
| Robert C Sehring |
Corporate Officer | Oct 20, 2017 | |
| Corporate Director | Oct 20, 2017 | ||
| W-2 Managing Employee |
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 | Jan 1, 2021 | |
| Michelle L Jones |
Contracted Managing Employee |
Dec 1, 2022 | |
| Operational/Managerial Control |
Dec 1, 2022 | ||
| Clyde M Grady |
Contracted Managing Employee |
Dec 1, 2022 | |
| Operational/Managerial Control |
Dec 1, 2022 | ||
| Brian J Silverstein |
Corporate Director | Oct 1, 2015 | |
| 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 |
|---|---|---|---|---|
| O20221114000814 | IL | Part a Provider - Rural Health Clinic | 8628038015 | Practice locations: Abingdon, IL |
National Provider Directory
- Tax ID family
- St Mary Medical CNTR
- Part of
- Eastland Med Plaza Surg
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
100 N Monroe St
Abingdon, IL 61410-1457
Mailing address
124 SW Adams St
Peoria, IL 61602-1308
Phone (309) 655-2850
Other names
- OSF Healthcare - Medical Group - Abingdon
Other providers in Abingdon, IL
- Abingdon Cusd 217
- Abingdon-Avon Cusd 276
- Sandra Marie Boggs
- Jeffry James Ensign
- St. Mary Medical Center
- Unlimited Development, Inc
All providers in Abingdon, IL · Rural Health Clinic/Center 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.