NPIMap

Organization Active NPI

Memorial Physician Services

  • Rural Health Clinic/Center
  • Petersburg, IL
National Provider Identifier
1790038099
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
1 Centre Dr
Petersburg, IL 62675-9467
Phone
(217) 632-7761
Fax
(217) 632-0312
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

1 Centre Dr
Petersburg, IL 62675-9467

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
143936OtherRHC MEDICARE PTAN

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130116000579 IL Part A Provider - Rural Health Clinic 9032005681 Practice locations: Petersburg, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1790038099. Details of each certification follow.

Rural health clinic certification: CCN 143936

Legal name
MEMORIAL PHYSICIAN SERVICES
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 19, 1996
Last certification
Feb 17, 2021
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
1 Centre Drive
Petersburg, IL 62675-9467

Other NPIs with the same Medicare PAC ID 5

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

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 16

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 DirectorBoard Member Jan 12, 2023
David B Sandercock Individual Corporate DirectorBoard Member Jan 10, 2024
Robert J Ellison Individual Corporate DirectorBoard Member Jan 14, 2026
Mandy C. Eaton Individual Corporate OfficerPresident & Ceo MH Apr 1, 2025
Nathan Pyle Individual Corporate DirectorBoard Member Jan 12, 2023
Kimberly R Beggs Individual Corporate OfficerPresident and Ceo MPS Jul 1, 2024
W-2 Managing Employee Dec 18, 2000
Tanya R Andricks Individual Corporate DirectorBoard Member Jan 14, 2026
Memorial Health System Organization, Springfield, IL Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 2013 100%
Anthony M Griffin Individual Corporate DirectorBoard Member Jan 10, 2018
Judi Harlan Individual W-2 Managing EmployeeNetwork Development & Partnerships Mar 1, 2020
Ted R Clark Individual Corporate OfficerBoard Member Jan 14, 2026
Kathryn J Keim Individual Corporate OfficerSenior VP & Cfo Jan 1, 2019
W-2 Managing EmployeeSenior VP & Cfo Jan 1, 2019
Stephanie Seaman Individual W-2 Managing EmployeeProvider Enrollment Coordinator Feb 3, 2014
Henry Hurwitz Individual Corporate DirectorBoard Member Jan 29, 2025
Amir J Wahab Individual Corporate DirectorBoard Member Sep 8, 2021
Ann E Bowling Individual W-2 Managing EmployeeDirector Apr 5, 2010

Owners & managing parties with NPI records 6

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": "1790038099",
    "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": "1 CENTRE DR",
            "city": "PETERSBURG",
            "state": "IL",
            "postal_code": "626759467",
            "telephone_number": "217-632-7761",
            "fax_number": "217-632-0312"
        }
    ],
    "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": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RHC MEDICARE PTAN",
            "identifier": "143936",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Petersburg, IL

Sources for this page

Verify at the official NPI Registry.