Provider Demographics
NPI:1326079245
Name:SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Entity Type:Organization
Organization Name:SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Other - Org Name:TERRIER CARE
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 1:109 CALIFORNIA ST
Mailing Address - Street 2:P O BOX 577
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 1:1301 E WALNUT ST RM J120
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5004
Practice Address - Country:US
Practice Address - Phone:618-457-3371
Practice Address - Fax:618-457-8931
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-06
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
640702OtherMEDICARE GROUP NUMBER
640702OtherMEDICARE GROUP NUMBER
141016Medicare Oscar/Certification
IL=========015Medicaid