Physician Services Corporation of Southern Illinois Inc.
Organization Active NPI Internal Medicine Physician · Mount Vernon, IL
NPI 1831101807 · NPPES record last updated Aug 25, 2015
Key facts
- NPI
- 1831101807
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Internal Medicine Physician 207R00000X
- Legal business name
- PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS INC.
- Practice address
- 4218 Lincolnshire Dr
Mount Vernon, IL 62864-2156 - Phone
- (618) 899-3600
- NPI assigned
- Aug 11, 2006
- Organization subpart
- No
Authorized official
- Name
- Deland Evischi
- Title
- VP Finance Smgsmg
- Phone
- (618) 899-1040
Owners & managing parties with NPI records 19
-
Ralph I Latta, MD
-
Sudeep Nair, MD
-
Prateek Srinet, M.D.
-
Mahvish Zahoor, MD
-
Rajiv N Patel, M.D.
Member of 1
Facilities with the same owner 30
Practitioners 376
-
Youssef Nmi Abdulnabi, M.D.
-
Linda Georgette Boulware, APRN
-
Christanna Marie Brown, BSN, RNFA, CNOR
-
Erbert Caceres, MD
-
Hong Chen, MD
-
Rachel Ellnetta Cox, APRN, FNP-BC
-
Melanie Cross, FNP
-
Ashley Daniels, FNP
-
Jason A Davison, NP-C
-
Robert F Dons, MD
-
Samuel J. Feinberg, M.D.
-
Camille Deanna Greider, MSN,RN,FNP-BC
-
Shelby Guthrie, FNP
-
Robert Lawrence Hatchett, M.D.
-
Ashley C Hofer, NP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in IL
Rural health clinic certification: CCN 783803
- Legal name
- PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS INC
- Doing business as
- SSM HEALTH MEDICAL GROUP
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jan 1, 2009
- Last certification
- Feb 17, 2022
- Ownership / control type
- 1B
- Organization structure
- Corporation · Proprietary
- Incorporated
- Jun 6, 1997 in IL
- Enrollment address
- 1441 W Broadway
Centralia, IL 62801-5613
All disclosed owners & managing parties 15
| Name | Role | Since | Share |
|---|---|---|---|
| Mahvish Zahoor |
Corporate Director |
Jan 1, 2019 | |
| Prateek Srinet |
Corporate Director |
Jan 1, 2019 | |
| Ralph I Latta |
Corporate Director |
Jan 1, 2019 | |
| Damon R Harbison |
Corporate Director |
Jan 1, 2019 | |
| Rajiv N Patel |
Corporate Director |
Jan 1, 2019 | |
| Kerry Swanson |
Operational/Managerial Control |
Apr 3, 2017 | |
| Tatiana Ramirez Dominguez |
Corporate Director |
Jan 1, 2019 | |
| SSM Health Care Corporation |
5% Or Greater Indirect Ownership Interest | Jan 1, 2008 | 100% |
| Matthew Kinsella |
Corporate Officer |
Nov 1, 2016 | |
| Operational/Managerial Control |
Nov 1, 2016 | ||
| Julie Long |
Corporate Director |
Jan 1, 2019 | |
| Sudeep Nair |
Corporate Director |
Jan 1, 2019 | |
| Steven Hubler-Marti |
Corporate Director |
Jan 1, 2019 | |
| Timothy Buller |
Corporate Officer |
Jan 1, 2019 | |
| Operational/Managerial Control |
Jan 1, 2019 | ||
| SSM Regional Health Services |
5% Or Greater Direct Ownership Interest | Jan 1, 2008 | 100% |
| Laura Kaiser |
Corporate Officer |
Jan 1, 2019 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040304000583 | IL | Part B Supplier - Clinic/Group Practice | 9234022567 |
Receives reassigned benefits from 299 practitioners Practice locations: Mount Vernon, IL; Nashville, IL; Pinckneyville, IL; Salem, IL; Wayne City, IL; O Fallon, IL; Benton, IL; Breese, IL… |
| O20080927000264 | IL | Part a Provider - Rural Health Clinic | 9234022567 | Practice locations: Centralia, IL |
National Provider Directory
Locations (25 of 39)
501 N Du Quoin St
Benton, IL 62812
Phone (618) 435-5362
9 N Rend Lake Plz
Benton, IL 62812
Phone (618) 435-5362
1052 M L King Dr
Ste 100
Centralia, IL 62801
444 N Pleasant Ave
Centralia, IL 62801
Phone (618) 436-5665
1054 Martin Luther King Dr
Ste 221
Centralia, IL 62801
1050 Martin Luther King Dr
Ste 104
Centralia, IL 62801
Phone (618) 532-6330
1054 M L King Dr
Ste 1
Centralia, IL 62801
1003 E McCord St
Centralia, IL 62801
Phone (618) 436-5231
1011 W Broadway
Centralia, IL 62801
Phone (618) 532-9050
1054 Martin Luther King Dr
Ste 125
Centralia, IL 62801
Phone (618) 436-5200
1054 M L King Dr
#105
Centralia, IL 62801
Phone (618) 436-5270
1308 Wells Street Rd
Du Quoin, IL 62832
Phone (618) 542-5421
602 S 42nd St
#B
Mount Vernon, IL 62864
Phone (618) 899-3278
4103 S Water Tower Pl
Mount Vernon, IL 62864
Phone (618) 899-3500
1708 Jefferson Ave
Ste 250
Mount Vernon, IL 62864
Phone (618) 241-1747
1708 Jefferson Ave
Ste 200
Mount Vernon, IL 62864
Phone (618) 244-1234
1708 Jefferson Ave
Ste 220
Mount Vernon, IL 62864
Phone (618) 899-3740
1708 Jefferson Ave
Ste 100
Mount Vernon, IL 62864
Phone (618) 241-1360
2 Good Samaritan Way
Ste 235
Mount Vernon, IL 62864
Phone (618) 899-3970
4200 Williamson Pl
Mount Vernon, IL 62864
Phone (618) 242-7819
201 N 27th St
Ste C
Mount Vernon, IL 62864
2 Good Samaritan Way
Ste 400
Mount Vernon, IL 62864
Phone (618) 899-3640
1109 S 42ND St
Mount Vernon, IL 62864
4106 S Water Tower Pl
Ste 420
Mount Vernon, IL 62864
2 Good Samaritan Way
Ste 320
Mount Vernon, IL 62864
Phone (618) 899-1944
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Internal Medicine Physician |
207R00000X | Yes | ||
| Obstetrics & Gynecology Physician |
207V00000X | |||
| Otolaryngology Physician |
207Y00000X | |||
| Pediatrics Physician |
208000000X | |||
| Surgery Physician |
208600000X | |||
| Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician |
208G00000X | |||
| Rural Health Clinic/Center | 261QR1300X | IL | ||
| Physician Assistant |
363A00000X |
Addresses
Primary practice location
4218 Lincolnshire Dr
Mount Vernon, IL 62864-2156
Mailing address
4218 Lincolnshire Dr
Mount Vernon, IL 62864-2156
Phone (618) 899-3600
Other names
- SSM Health Medical Group
Other providers in Mount Vernon, IL
- Shima Phoenix
- Physician Rural Health Clinic of Jefferson County
- Physician Services Corp of Southern Illinois
- Physician Services Corporation of Southern Illinois
- Physician Services Corporation of Southern Illinois Inc
- Physician Services Corporation of Southern Illinois S.C
- Physicians Surgery Center at Good Samaritan, LLC
- Matt Christopher Pina
- Lauren Marie Pingsterhaus
- Kerry Lynn Pitchford
All providers in Mount Vernon, IL · Internal Medicine Physician in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 25, 2015. 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.