Board of Trustees of Southern Illinois University
Organization Active NPI Federally Qualified Health Center (FQHC) · Lincoln, IL
NPI 1972049641 · NPPES record last updated Jan 9, 2025
Key facts
- NPI
- 1972049641
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
- Practice address
- 109 3Rd St
Lincoln, IL 62656-2604 - Phone
- (217) 735-2317
- Fax
- (217) 732-6943
- NPI assigned
- Jan 18, 2017
- Organization subpart
- Yes
- Parent organization (as reported)
- BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Authorized official
- Name
- Iris Wesley
- Title
- Ceo
- Phone
- (217) 545-7876
Owners & managing parties with NPI records 19
-
Michal Dynda, MD
Owned or controlled facilities with NPI records 11
Other NPIs with the same Medicare PAC ID 18
Corporate family (same tax ID) 28
Facilities with the same owner 10
Practitioners 139
-
Samantha A Agar, M.D.
-
Ahmad Al Turk, M.D.
-
Nour M D Albastt, MD
-
Janet R Albers, M.D.
-
Tracy A Aldridge, M.D.
-
Cesar S Arguelles, M.D.
-
Melissa Louise Ashley, FNP-BC
-
Max A Baier, NP
-
Jordyn Bailey, LCPC
-
Hannah J. Bettis, AGPCNP-BC
-
Priyanka Bhandari, M.D.
-
Mukul Bhattarai, MD.
-
Lori A Bland, NP-C
-
Sarah K Bockhold, MSW, LCSW
-
Rexanne Lagare Caga-Anan, M.D.
-
Mikeal A Capati, APRN
-
Elizabeth S Carriker, LCSW
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
Federally qualified health center certification: CCN 781871
- Legal name
- BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
- Doing business as
- SIU CENTER FOR FAMILY MEDICINE - LINCOLN
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Mar 16, 2017
- Last certification
- Mar 16, 2017
- Ownership / control type
- For profit – corporation
- Organization structure
- Other · Non-profit
- Incorporated
- Oct 1, 2012 in IL
- Enrollment address
- 109 3Rd St
Lincoln, IL 62656-2604
All disclosed owners & managing parties 14
| Name | Role | Since | Share |
|---|---|---|---|
| Nancy S Zimmers |
Corporate Director |
Jun 1, 2016 | |
| Michal Dynda |
Corporate Officer |
Jun 1, 2016 | |
| Iris E Wesley |
Corporate Officer |
Jun 1, 2016 | |
| W-2 Managing Employee |
Mar 1, 2013 | ||
| Drusilla P Lobmaster |
Corporate Director |
Jun 1, 2016 | |
| Keith Edward Rechner |
Corporate Director |
Jun 1, 2016 | |
| Veatrice G Crawford |
Corporate Officer |
Jun 1, 2016 | |
| Stuart H Shiffman |
Corporate Director |
Jun 1, 2016 | |
| Board of Trustees of Southern Illinois University |
Operational/Managerial Control | Oct 1, 2012 | 100% |
| Jan R Gambach |
Corporate Director |
Jun 1, 2016 | |
| Julie Kappes |
Corporate Director | Apr 1, 2017 | |
| Zevernett Holloway |
Corporate Director | Apr 1, 2017 | |
| Stephanie K Standish |
Corporate Director |
Jun 1, 2016 | |
| Marcheta Hays |
Corporate Director | Jul 1, 2017 | |
| Waverly Robinson |
Corporate Director | Feb 1, 2022 |
All facility ownership & control disclosures 11
| Facility | Type | Role | Since |
|---|---|---|---|
| Siu Center for Family Medicine |
Federally qualified health center | Operational/Managerial Control (100%) | Jun 8, 2012 |
| Siu Quincy Family Medicine |
Federally qualified health center | Operational/Managerial Control (100%) | Jun 8, 2012 |
| Board of Trustees of Southern Illinois University |
Federally qualified health center | Operational/Managerial Control | Oct 1, 2012 |
| Siu Center for Family Medicine - Iwc |
Federally qualified health center | Operational/Managerial Control (100%) | Aug 1, 2017 |
| Siu Center for Family Medicine-Transitions of Western Illinois |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) Operational/Managerial Control |
Apr 2, 2018 Apr 2, 2018 |
| Siu Center for Family Medicine - Carbondale |
Federally qualified health center | Operational/Managerial Control (100%) | Oct 1, 2012 |
| Siu Center for Family Medicine-Taylorville |
Federally qualified health center | Operational/Managerial Control (100%) | Mar 10, 2020 |
| Board of Trustees of Southern Illinois University |
Federally qualified health center | Other (100%) | Oct 1, 2012 |
| Siu Center for Family Medicine-Jacksonville |
Federally qualified health center | Operational/Managerial Control | Oct 1, 2012 |
| Siu Center for Healthy Aging and Wellness |
Federally qualified health center | Operational/Managerial Control | Oct 1, 2012 |
| Siu Center for Family Medicine - Sangamon County Health |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) Operational/Managerial Control (100%) |
Oct 1, 2012 Oct 1, 2012 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20170316002207 | IL | Part a Provider - Federally Qualified Health Center (FQHC) | 4486667888 | Practice locations: Lincoln, IL |
National Provider Directory
- Tax ID family
- DRS Herald and Thompson
- Part of
- DRS Herald and Thompson
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes | ||
| Primary Care Clinic/Center | 261QP2300X |
Addresses
Primary practice location
109 3Rd St
Lincoln, IL 62656-2604
Mailing address
PO Box 19639
Springfield, IL 62794-9639
Phone (217) 545-8000
Other names
- SIU Center for Family Medicine - Lincoln
Other providers in Lincoln, IL
- Ashley N Bennett
- Erica Beutel
- Cynthia D Bivin
- Richard Ethan Bivin
- Millicent L. Bliesener
- Kyley Jo Bolk
- Ashley Brinner
- Jenilee Brocaille
- Karla J Carr
- Dennis M Carroll
All providers in Lincoln, IL · Federally Qualified Health Center (FQHC) in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 9, 2025. 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.