Provider Demographics
NPI:1285185173
Name:SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Entity Type:Organization
Organization Name:SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Other - Org Name:SHAWNEE HEALTH CARE, SAME DAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-956-9521
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:109 CALIFORNIA ST.
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:618-985-6860
Practice Address - Street 1:404 S. LEWIS LANE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-519-9200
Practice Address - Fax:618-549-1288
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-17
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 261QF0400X
ILH80CS00667207Q00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL640701Medicare PIN