Provider Demographics
NPI:1356677058
Name:SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Entity Type:Organization
Organization Name:SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Other - Org Name:SHAWNEE HEALTH CARE, MARION DENTAL
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 STREET
Mailing Address - Street 2:PO 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 1:3115 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5235
Practice Address - Country:US
Practice Address - Phone:618-969-8600
Practice Address - Fax:618-997-1214
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-30
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 1223P0221X, 124Q00000X, 126800000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty