NPIMap

Organization Active NPI

Board of Trustees of Southern Illinois University

Doing business as SIU Center for Family Medicine - Lincoln

  • Federally Qualified Health Center (FQHC)
  • Lincoln, IL
National Provider Identifier
1972049641
Registry record updated Jan 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Doing business as
SIU Center for Family Medicine - Lincoln
Practice address
109 3Rd St
Lincoln, IL 62656-2604
Phone
(217) 735-2317
Fax
(217) 732-6943
NPI assigned
Jan 18, 2017
Last updated
Jan 9, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITYAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 9, 2025

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

Authorized official

Name
Iris Wesley
Title
Ceo
Phone
(217) 545-7876

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
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 1

  • SIU Center for Family Medicine - Lincoln Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170316002207 IL Part A Provider - Federally Qualified Health Center (FQHC) 4486667888 Practice locations: Lincoln, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1972049641. Details of each certification follow.

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
OtherNon-profit
Incorporated
Oct 1, 2012 in IL
Enrollment address
109 3Rd St
Lincoln, IL 62656-2604

Other NPIs with the same Medicare PAC ID 18

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

View all 18

National Provider Directory

National Provider Directory
Tax ID family
S a Torgerson MD29 organizations share this tax ID, including this one
Part of
S a Torgerson MD

Other organizations with this tax ID 28

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

View all 28

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Nancy S Zimmers Individual Corporate DirectorDirector Jun 1, 2016
Michal Dynda Individual Corporate OfficerChief Medical Officer Jun 1, 2016
Iris E Wesley Individual Corporate OfficerCeo Jun 1, 2016
W-2 Managing EmployeeCeo Mar 1, 2013
Drusilla P Lobmaster Individual Corporate DirectorDirector Jun 1, 2016
Keith Edward Rechner Individual Corporate DirectorDirector Jun 1, 2016
Veatrice G Crawford Individual Corporate OfficerBoard President Jun 1, 2016
Stuart H Shiffman Individual Corporate DirectorDirector Jun 1, 2016
Board of Trustees of Southern Illinois University Organization, Lincoln, IL Operational/Managerial Control Oct 1, 2012 100%
Jan R Gambach Individual Corporate DirectorDirector Jun 1, 2016
Julie Kappes Individual Corporate Director Apr 1, 2017
Zevernett Holloway Individual Corporate Director Apr 1, 2017
Stephanie K Standish Individual Corporate DirectorDirector Jun 1, 2016
Marcheta Hays Individual Corporate Director Jul 1, 2017
Waverly Robinson Individual Corporate Director Feb 1, 2022

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

All facility ownership & control disclosures 11

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Siu Center for Family MedicineSpringfield, IL, CCN 141168 Federally qualified health center Operational/Managerial Control (100%) Jun 8, 2012
Siu Quincy Family MedicineQuincy, IL, CCN 781837 Federally qualified health center Operational/Managerial Control (100%) Jun 8, 2012
Board of Trustees of Southern Illinois UniversityDecatur, IL, CCN 781876 Federally qualified health center Operational/Managerial Control Oct 1, 2012
Siu Center for Family Medicine - IwcSpringfield, IL, CCN 781897 Federally qualified health center Operational/Managerial Control (100%) Aug 1, 2017
Siu Center for Family Medicine-Transitions of Western IllinoisQuincy, IL, CCN 781904 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 - CarbondaleCarbondale, IL, CCN 781933 Federally qualified health center Operational/Managerial Control (100%) Oct 1, 2012
Siu Center for Family Medicine-TaylorvilleTaylorville, IL, CCN 781937 Federally qualified health center Operational/Managerial Control (100%) Mar 10, 2020
Board of Trustees of Southern Illinois UniversityPittsfield, IL, CCN 781942 Federally qualified health center Other (100%) Oct 1, 2012
Siu Center for Family Medicine-JacksonvilleJacksonville, IL, CCN 781066 Federally qualified health center Operational/Managerial Control Oct 1, 2012
Siu Center for Healthy Aging and WellnessSpringfield, IL, CCN 141809 Federally qualified health center Operational/Managerial Control Oct 1, 2012
Siu Center for Family Medicine - Sangamon County HealthSpringfield, IL, CCN 781147 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Oct 1, 2012
Oct 1, 2012

Owned or controlled facilities with NPI records 11

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 10

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

NPI Registry JSON

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

{
    "created_epoch": "1484697600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1736380800000",
    "number": "1972049641",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 19639",
            "city": "SPRINGFIELD",
            "state": "IL",
            "postal_code": "627949639",
            "telephone_number": "217-545-8000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "109 3RD ST",
            "city": "LINCOLN",
            "state": "IL",
            "postal_code": "626562604",
            "telephone_number": "217-735-2317",
            "fax_number": "217-732-6943"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY",
        "enumeration_date": "2017-01-18",
        "last_updated": "2025-01-09",
        "certification_date": "2025-01-09",
        "status": "A",
        "authorized_official_last_name": "WESLEY",
        "authorized_official_first_name": "IRIS",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "217-545-7876"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SIU Center for Family Medicine - Lincoln",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lincoln, IL

Sources for this page

Verify at the official NPI Registry.