NPIMap

Organization Active NPI

St Mary Medical Center

Doing business as OSF Healthcare - Medical Group - Knoxville

  • Rural Health Clinic/Center
  • Knoxville, IL
National Provider Identifier
1801512165
Registry record updated Mar 18, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
ST MARY MEDICAL CENTER
Doing business as
OSF Healthcare - Medical Group - Knoxville
Practice address
104 S Broad St
Knoxville, IL 61448-1339
Phone
(309) 289-2335
NPI assigned
Oct 18, 2022
Last updated
Mar 18, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
OSF HEALTHCARE SYSTEMAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 18, 2024

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

Authorized official

Name
Robert C Sehring
Title
Ceo, Osf Healthcare System
Phone
(309) 655-2850

Specialties & licenses 1

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

Addresses

Primary practice location

104 S Broad St
Knoxville, IL 61448-1339

Mailing address

124 SW Adams St
Peoria, IL 61602-1308
Phone (309) 655-2850

Other names 1

  • OSF Healthcare - Medical Group - Knoxville Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20221114001213 IL Part A Provider - Rural Health Clinic 8628038015 Practice locations: Knoxville, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1801512165. Details of each certification follow.

Rural health clinic certification: CCN 148648

Legal name
ST MARY MEDICAL CENTER
Doing business as
OSF HEALTHCARE - MEDICAL GROUP - KNOXVILLE
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
CorporationNon-profit
Enrollment address
904 E Main St
Knoxville, IL 61448-1539
Related CCNs
140064

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 7

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
14D0431359Osf Healthcare - Medical Group- Knoxville904 E Main St, Knoxville, IL 61448Certificate of waiverJan 17, 2028

National Provider Directory

National Provider Directory
Tax ID family
Fam Prac Ass Dba St Mar12 organizations share this tax ID, including this one
Part of
Osf Healthcare System

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 18

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

NameRoleSinceShare
Patricia a Brazeau Individual Corporate Officer Oct 1, 2006
Corporate Director Oct 1, 2006
Anne M Ziegler Individual Corporate Director Jan 1, 2021
Melanie R Mann Individual Corporate Officer Oct 6, 2024
Corporate Director Oct 1, 2006
August Querciagrossa Individual W-2 Managing EmployeeCeo Western Region Aug 17, 2022
Operational/Managerial ControlCeo Western Region Aug 17, 2022
Gerald J McShane Individual Corporate Director Sep 1, 1996
Osf Healthcare Ministries Organization, Peoria, IL Corporation, Non-profit Operational/Managerial Control Nov 1, 2024
Kathleen F Williams Individual Corporate Officer Nov 1, 2014
Corporate Director Jan 1, 2003
Kirsten M Largent Individual Corporate Officer Nov 8, 2024
W-2 Managing EmployeeChief Financial Officer Nov 8, 2024
Operational/Managerial ControlChief Financial Officer Nov 8, 2024
Lisa M Dekezel Individual W-2 Managing EmployeePresident Nov 18, 2019
Operational/Managerial ControlPresident Nov 18, 2019
Osf Healthcare System Organization, Peoria, IL Corporation, Non-profit, Chain home office Operational/Managerial Control Jan 1, 1966
Robert C Sehring Individual Corporate Officer Oct 20, 2017
Corporate Director Oct 20, 2017
W-2 Managing EmployeeChief Executive Officer Oct 20, 2017
Operational/Managerial ControlChief Executive Officer Oct 20, 2017
Judith a Duvall Individual Corporate Officer Oct 1, 2006
Corporate Director Oct 1, 1989
Carisa a Neumann Individual Corporate Director Jan 1, 2021
Michelle L Jones Individual Contracted Managing EmployeeClinic Manager Dec 1, 2022
Operational/Managerial ControlClinic Manager Dec 1, 2022
Clyde M Grady Individual Contracted Managing EmployeePhysician Director Dec 1, 2022
Operational/Managerial ControlPhysician Director Dec 1, 2022
Brian J Silverstein Individual Corporate Director Oct 1, 2015
Paula K Selamat Individual Corporate Director Oct 6, 2024
Bridget J Meidl Individual Corporate Director Nov 1, 2014

Owners & managing parties with NPI records 2

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

Facilities with the same owner 76

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

View all 76

NPI Registry JSON

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

{
    "created_epoch": "1666051200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710720000000",
    "number": "1801512165",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "124 SW ADAMS ST",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616021308",
            "telephone_number": "309-655-2850",
            "fax_number": "309-655-4878"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "104 S BROAD ST",
            "city": "KNOXVILLE",
            "state": "IL",
            "postal_code": "614481339",
            "telephone_number": "309-289-2335"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST MARY MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "OSF HEALTHCARE SYSTEM",
        "enumeration_date": "2022-10-18",
        "last_updated": "2024-03-18",
        "certification_date": "2024-03-18",
        "status": "A",
        "authorized_official_last_name": "SEHRING",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "CEO, OSF HEALTHCARE SYSTEM",
        "authorized_official_telephone_number": "309-655-2850"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "OSF Healthcare - Medical Group - Knoxville",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Knoxville, IL

Sources for this page

Verify at the official NPI Registry.