Provider Demographics
NPI: | 1639295314 |
---|---|
Name: | SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP |
Entity Type: | Organization |
Organization Name: | SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP |
Other - Org Name: | |
Other - Org Type: | |
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: | 109 CALIFORNIA ST |
Practice Address - Street 2: | |
Practice Address - City: | CARTERVILLE |
Practice Address - State: | IL |
Practice Address - Zip Code: | 62918-0577 |
Practice Address - Country: | US |
Practice Address - Phone: | 618-985-8221 |
Practice Address - Fax: | 618-985-6860 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-03-22 |
Last Update Date: | 2024-04-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 1041C0700X, 122300000X, 124Q00000X, 126800000X, 133V00000X, 207Q00000X, 207QA0000X, 207RP1001X, 207V00000X, 208000000X, 2084N0400X, 3336C0003X | |
261QF0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | Group - Multi-Specialty |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 122300000X | Dental Providers | Dentist | Group - Multi-Specialty | |
No | 124Q00000X | Dental Providers | Dental Hygienist | Group - Multi-Specialty | |
No | 126800000X | Dental Providers | Dental Assistant | Group - Multi-Specialty | |
No | 133V00000X | Dietary & Nutritional Service Providers | Dietitian, Registered | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207QA0000X | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 022 | Medicaid | |
IL | 020 | Medicaid | |
640701 | Other | MEDICARE PART B GROUP ID | |
IL | 10032052 | Other | BLUE CROSS BLUE SHIELD |
IL | CF3444 | Other | MEDICARE RAILROAD |
IL | 013 | Medicaid | |
IL | 024 | Medicaid | |
IL | 018 | Medicaid | |
IL | 019 | Medicaid | |
IL | 019 | Medicaid | |
IL | =========6291804 | Other | MEDICAID PAYEE NUMBER |
IL | =========005 | Medicaid | |
IL | =========017 | Medicaid | |
IL | 024 | Medicaid | |
IL | 022 | Medicaid | |
IL | 020 | Medicaid | |
IL | 10032052 | Other | BLUE CROSS BLUE SHIELD |
IL | =========014 | Medicaid | |
IL | CF3444 | Other | MEDICARE RAILROAD |
IL | 018 | Medicaid | |
IL | 141016 | Medicare Oscar/Certification | |
IL | =========016 | Medicaid | |
IL | =========005 | Medicaid | |
IL | =========004 | Medicaid | |
IL | 141069 | Medicare Oscar/Certification | |
IL | CF3444 | Other | MEDICARE RAILROAD |
IL | 020 | Medicaid | |
IL | =========023 | Medicaid | |
IL | 018 | Medicaid | |
IL | =========002 | Medicaid | |
IL | 141070 | Medicare Oscar/Certification | |
IL | 141816 | Medicare Oscar/Certification | |
IL | 141849 | Medicare Oscar/Certification |