NPIMap

Organization Active NPI

Southern Illinois Healthcare Foundation, Inc

Doing business as Millstadt Medical Clinic

  • Federally Qualified Health Center (FQHC)
  • Millstadt, IL
National Provider Identifier
1811236458
Registry record updated Feb 1, 2013
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
Doing business as
Millstadt Medical Clinic
Practice address
60 Regency PL
Millstadt, IL 62260-2210
Phone
(618) 476-9177
Fax
(618) 476-1890
NPI assigned
Feb 1, 2013
Last updated
Feb 1, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 1, 2013

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

Authorized official

Name
Larry McCulley
Title
Ceo
Phone
(618) 332-0694

Specialties & licenses 2

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

Addresses

Primary practice location

60 Regency PL
Millstadt, IL 62260-2210

Mailing address

2041 Goose Lake Rd
Sauget, IL 62206-2822
Phone (618) 332-0953

Other names 1

  • Millstadt Medical Clinic 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…
O20130308000481 IL Part A Provider - Federally Qualified Health Center (FQHC) 1456256874 Practice locations: Millstadt, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1811236458. Details of each certification follow.

Federally qualified health center certification: CCN 141187

Legal name
SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC
Doing business as
SIHF HEALTHCARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 20, 2013
Last certification
Mar 20, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 27, 1985 in IL
Enrollment address
60 Regency PL
Millstadt, IL 62260-2210

National Provider Directory

National Provider Directory
Tax ID family
Southern Illinois Hlthc38 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 15

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

NameRoleSinceShare
Percy McKinney Individual Corporate DirectorBoard Member Apr 22, 2024
Walter Hunter Individual Corporate OfficerVice Chairperson Feb 1, 2008
Gerard Hasenstab Individual Corporate DirectorBoard Member Jan 1, 2019
Dale Fiedler Individual Corporate DirectorBoard Member Jan 1, 2020
Debra Reed Individual Corporate DirectorBoard Member Jan 1, 2021
Larry W McCulley Individual Corporate OfficerChief Executive Officer Apr 1, 2010
Kenneth Hall Individual Corporate DirectorBoard Member Apr 1, 2015
Zoila Marty Individual Corporate DirectorBoard Member Sep 1, 2005
Ethel Manager Individual Corporate OfficerChairperson May 1, 1996
Crysten Calvert Individual Corporate OfficerVice Chairperson Jan 1, 2023
Daniel Winkle Individual W-2 Managing EmployeeAd; May 1, 2025
Anna Marie Nelson Individual Corporate DirectorBoard Member Jan 1, 2010
Richard Sinclair Individual Corporate DirectorBoard Member Aug 1, 2006
Darrel Sterling Individual Corporate DirectorBoard Member Jan 1, 2023
Irma Golliday Individual Corporate DirectorBoard Member 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 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1359676800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1359676800000",
    "number": "1811236458",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2041 GOOSE LAKE RD",
            "city": "SAUGET",
            "state": "IL",
            "postal_code": "622062822",
            "telephone_number": "618-332-0953",
            "fax_number": "618-332-2487"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "60 REGENCY PL",
            "city": "MILLSTADT",
            "state": "IL",
            "postal_code": "622602210",
            "telephone_number": "618-476-9177",
            "fax_number": "618-476-1890"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-02-01",
        "last_updated": "2013-02-01",
        "status": "A",
        "authorized_official_last_name": "MCCULLEY",
        "authorized_official_first_name": "LARRY",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "618-332-0694"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "IL",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "IL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Millstadt Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Millstadt, IL

Sources for this page

Verify at the official NPI Registry.