NPIMap

Organization Active NPI

Southern Illinois Healthcare Foundation, Inc.

  • Federally Qualified Health Center (FQHC)
  • East Saint Louis, IL
National Provider Identifier
1770648917
Registry record updated Jul 29, 2009
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
2568 N 41St St
East Saint Louis, IL 62201-2204
Phone
(618) 482-4015
Fax
(618) 482-4806
NPI assigned
Dec 27, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 29, 2009

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

Authorized official

Name
Mr. Larry McCulley
Title
President
Phone
(618) 332-0783

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X

Addresses

Primary practice location

2568 N 41St St
East Saint Louis, IL 62201-2204

Mailing address

8080 State St
East Saint Louis, IL 62203-1808
Phone (618) 397-3303

Other names 1

  • Fairmont City 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…
O20081030000237 IL Part A Provider - Federally Qualified Health Center (FQHC) 1456256874 Practice locations: Fairmont City, IL

Federally qualified health center certification: CCN 141976

Legal name
SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC
Doing business as
SIHF HEALTHCARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 12, 2004
Last certification
Feb 12, 2004
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 27, 1985 in IL
Enrollment address
2568 N 41St St
Fairmont City, IL 62201-2211

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 11

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Walter Hunter Individual Corporate Director Mar 1, 2008
Gerard Hasenstab Individual Corporate Director Jan 1, 2019
Dale Fiedler Individual Corporate Director Jan 1, 2020
James F Spinner Individual Corporate Director Oct 12, 1998
W-2 Managing Employee Oct 12, 1998
Larry W McCulley Individual Corporate OfficerCheif Executive Officer Apr 1, 2010
Kenneth Hall Individual Corporate Director Apr 1, 2019
Zoila Marty Individual Corporate Director Sep 1, 2005
Ethel Manager Individual Corporate Director May 1, 1996
Anna Marie Nelson Individual Corporate Director Jan 1, 2010
Richard Sinclair Individual Corporate Director Aug 1, 2006
Irma Golliday Individual Corporate Director 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 5

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": "1167177600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1248825600000",
    "number": "1770648917",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8080 STATE ST",
            "city": "EAST SAINT LOUIS",
            "state": "IL",
            "postal_code": "622031808",
            "telephone_number": "618-397-3303",
            "fax_number": "618-397-7802"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2568 N 41ST ST",
            "city": "EAST SAINT LOUIS",
            "state": "IL",
            "postal_code": "622012204",
            "telephone_number": "618-482-4015",
            "fax_number": "618-482-4806"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-27",
        "last_updated": "2009-07-29",
        "status": "A",
        "authorized_official_last_name": "MCCULLEY",
        "authorized_official_first_name": "LARRY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "618-332-0783",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "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
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fairmont City Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in East Saint Louis, IL

Sources for this page

Verify at the official NPI Registry.