NPIMap

Organization Active NPI

Physician Services Corporation of Southern Illinois Inc.

Doing business as SSM Health Medical Group

  • Internal Medicine Physician
  • Mount Vernon, IL
National Provider Identifier
1831101807
Registry record updated Aug 25, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS INC.
Doing business as
SSM Health Medical Group
Practice address
4218 Lincolnshire Dr
Mount Vernon, IL 62864-2156
Phone
(618) 899-3600
NPI assigned
Aug 11, 2006
Last updated
Aug 25, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 25, 2015

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

Authorized official

Name
Deland Evischi
Title
VP Finance Smgsmg
Phone
(618) 899-1040

Specialties & licenses 9

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X Primary
Obstetrics & Gynecology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207V00000X
Otolaryngology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Y00000X
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208600000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208G00000X
Rural Health Clinic/Center 261QR1300X IL
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 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 1

  • SSM Health Medical Group Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1831101807. Details of each certification follow.

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
CorporationProprietary
Incorporated
Jun 6, 1997 in IL
Enrollment address
1441 W Broadway
Centralia, IL 62801-5613

National Provider Directory

National Provider Directory

Locations (25 of 51)

501 N Du Quoin St
Benton, IL 62812
Phone (618) 435-5362

9 N Rend Lake Plz
Benton, IL 62812
Phone (618) 435-5362

1665 N 4th St
Breese, IL 62230
Phone (618) 526-8800

35 Albany Rd
Ste E
Carbondale, IL 62903
Phone (618) 241-2128

1050 Martin Luther King Dr
Ste 104
Centralia, IL 62801
Phone (618) 532-6330

1050 Martin Luther King Dr
Ste 105
Centralia, IL 62801
Phone (618) 436-5270

1050 Martin Luther King Dr
Ste 109
Centralia, IL 62801
Phone (618) 532-0998

1052 M L King Dr
Ste 100
Centralia, IL 62801

1054 M L King Dr
#105
Centralia, IL 62801
Phone (618) 436-5270

1054 M L King Dr
Ste 1
Centralia, IL 62801

1054 Martin Luther King Dr
Ste 125
Centralia, IL 62801
Phone (618) 436-5200

1054 Martin Luther King Dr
Ste 221
Centralia, IL 62801

1054 Martin Luther King Dr
Ste 222
Centralia, IL 62801
Phone (618) 244-3200

1054 Martin Luther King Dr
Ste 224
Centralia, IL 62801
Phone (618) 436-5231

1441 W Broadway
Centralia, IL 62801
Phone (618) 532-0810

430 N Pleasant Ave
Centralia, IL 62801
Phone (618) 436-5995

936 M L King Dr
Centralia, IL 62801
Phone (618) 532-6439

24 Veterans Dr
Harrisburg, IL 62946

121 N 13th St
Ste 4
Herrin, IL 62948

205 Huron St
Irvington, IL 62848
Phone (618) 249-6203

1109 S 42ND St
Mount Vernon, IL 62864

13023 N Shiloh Dr
Mount Vernon, IL 62864
Phone (618) 244-7701

1702 Broadway St
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

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
Mahvish Zahoor Individual Corporate DirectorBoard Member Jan 1, 2019
Prateek Srinet Individual Corporate DirectorBoard Member Jan 1, 2019
Ralph I Latta Individual Corporate DirectorBoard Member Jan 1, 2019
Damon R Harbison Individual Corporate DirectorBoard Member Jan 1, 2019
Rajiv N Patel Individual Corporate DirectorBoard Member Jan 1, 2019
Kerry Swanson Individual Operational/Managerial ControlPresident, SSM Health Good Sam Apr 3, 2017
Tatiana Ramirez Dominguez Individual Corporate DirectorBoard Member Jan 1, 2019
SSM Health Care Corporation Organization, Saint Louis, MO Corporation, Non-profit 5% Or Greater Indirect Ownership Interest Jan 1, 2008 100%
Matthew Kinsella Individual Corporate OfficerRegional Cfo Nov 1, 2016
Operational/Managerial ControlRegional Cfo Nov 1, 2016
Julie Long Individual Corporate DirectorBoard Member Jan 1, 2019
Sudeep Nair Individual Corporate DirectorBoard Member Jan 1, 2019
Steven Hubler-Marti Individual Corporate DirectorBoard Member Jan 1, 2019
Timothy Buller Individual Corporate OfficerRegional Cfo - Financial Strategy Jan 1, 2019
Operational/Managerial ControlRegional Cfo - Financial Strategy Jan 1, 2019
SSM Regional Health Services Organization, Saint Louis, MO Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 2008 100%
Laura Kaiser Individual Corporate OfficerPresident/Ceo, SSM Health Jan 1, 2019

Owners & managing parties with NPI records 19

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

View all 19

Facilities with the same owner 30

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

View all 30

Practitioners & affiliated clinicians

Practitioners 375

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.

View all 375

NPI Registry JSON

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

{
    "created_epoch": "1155254400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1440460800000",
    "number": "1831101807",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4218 LINCOLNSHIRE DR",
            "city": "MOUNT VERNON",
            "state": "IL",
            "postal_code": "628642156",
            "telephone_number": "618-899-3600"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4218 LINCOLNSHIRE DR",
            "city": "MOUNT VERNON",
            "state": "IL",
            "postal_code": "628642156",
            "telephone_number": "618-899-3600"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-11",
        "last_updated": "2015-08-25",
        "status": "A",
        "authorized_official_last_name": "EVISCHI",
        "authorized_official_first_name": "DELAND",
        "authorized_official_title_or_position": "VP FINANCE SMGSMG",
        "authorized_official_telephone_number": "618-899-1040"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Otolaryngology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208G00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "IL",
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SSM Health Medical Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mount Vernon, IL

Sources for this page

Verify at the official NPI Registry.