NPIMap

Organization Active NPI

Shawnee Health Service and Development Corp

Doing business as Marion Wellness

  • Federally Qualified Health Center (FQHC)
  • Marion, IL
National Provider Identifier
1881624161
Registry record updated Jul 17, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Doing business as
Marion Wellness
Practice address
1700 Wildcat Dr Ste a
Marion, IL 62959-1513
Phone
(618) 969-8228
Fax
(618) 998-0880
NPI assigned
Jul 3, 2006
Last updated
Jul 17, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORPAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 17, 2024

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

Authorized official

Name
Christina Carney
Title
Ceo
Phone
(618) 956-9521

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X
General Practice DentistryGroup: 193200000X MULTI-SPECIALTY GROUP 1223G0001X
Dental HygienistGroup: 193200000X MULTI-SPECIALTY GROUP 124Q00000X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

1700 Wildcat Dr Ste a
Marion, IL 62959-1513

Mailing address

109 California St
P O Box 577
Carterville, IL 62918-0577
Phone (618) 985-8221

Other names 1

  • Marion Wellness Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031120000454 IL Part B Supplier - Clinic/Group Practice 1658285671 Receives reassigned benefits from 54 practitioners
28 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Carterville, IL; Murphysboro, IL; Marion, IL; Herrin, IL; Carbondale, IL
O20050322000962 IL Part A Provider - Federally Qualified Health Center (FQHC) 1658285671 1 other NPI on this enrollment
Practice locations: Marion, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881624161. Details of each certification follow.

Federally qualified health center certification: CCN 141011

Legal name
SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Doing business as
MARION WELLNESS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 15, 2005
Last certification
Apr 15, 2005
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
May 2, 1972 in IL
Enrollment address
1700 Wildcat Dr
Ste a
Marion, IL 62959-1435

Other NPIs with the same Medicare PAC ID 21

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

View all 21

Other NPIs on the same Medicare enrollment 20

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 20

National Provider Directory

National Provider Directory
Tax ID family
Shawnee Health Service37 organizations share this tax ID, including this one
Part of
Shawnee Health Service

Other organizations with this tax ID 36

Organizations that report the same tax identification number in the National Provider Directory.

View all 36

Locations

1108 Grand Ave
Johnston City, IL 62951
Phone (618) 983-7561

1500 Jefferson Ave
Johnston City, IL 62951

420 E Main St
Marion, IL 62959
Phone 6189938534 ext. 266

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
Kevin Lipe Individual Corporate DirectorVice President Feb 4, 2021
Carolin Harvey Individual Corporate DirectorBoard Member Aug 5, 2021
Leigh Ann Hacker Individual W-2 Managing EmployeeCredentialing Specialist Sep 27, 2018
George Marin Individual Corporate DirectorBoard Member Jun 2, 2022
Flora Broadnex Individual Corporate DirectorBoard Member Oct 3, 2024
Karen Cripps Individual Corporate DirectorBoard Member Feb 6, 2025
Jeffrey Cooper Individual Corporate OfficerChief Financial Officer Jul 1, 2008
W-2 Managing EmployeeChief Financial Officer Jul 1, 2008
Julian Valdes Individual Corporate DirectorPresident May 5, 2022
Dale Ritzel Individual Corporate DirectorBoard Member Mar 7, 2013
Teresa Wisely Individual W-2 Managing EmployeeCredentialing Specialist Jun 1, 2022
Jose Llamas Individual Corporate DirectorBoard Member Oct 3, 2019
Arun Subramanian Individual Corporate DirectorBoard Member Oct 1, 2015
Elizabeth Cook Individual Corporate DirectorBoard Member Jan 2, 2025
Christina Carney Individual Corporate OfficerChief Executive Officer Aug 1, 2023
W-2 Managing EmployeeChief Executive Officer Aug 1, 2023
Shane Carsrud Individual Corporate DirectorSecretary / Treasurer Oct 7, 2021

Practitioners & affiliated clinicians

Practitioners 37

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 37

NPI Registry JSON

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

{
    "created_epoch": "1151884800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1721174400000",
    "number": "1881624161",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "109 CALIFORNIA ST",
            "address_2": "P O BOX 577",
            "city": "CARTERVILLE",
            "state": "IL",
            "postal_code": "629180577",
            "telephone_number": "618-985-8221",
            "fax_number": "618-985-6860"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1700 WILDCAT DR STE A",
            "city": "MARION",
            "state": "IL",
            "postal_code": "629591513",
            "telephone_number": "618-969-8228",
            "fax_number": "618-998-0880"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP",
        "enumeration_date": "2006-07-03",
        "last_updated": "2024-07-17",
        "certification_date": "2024-07-17",
        "status": "A",
        "authorized_official_last_name": "CARNEY",
        "authorized_official_first_name": "CHRISTINA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "618-956-9521"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "124Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dental Hygienist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Marion Wellness",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Marion Wellness",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Marion, IL

Sources for this page

Verify at the official NPI Registry.