Basic Information
Provider Information | |||||||||
NPI: | 1073745345 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SHAWNEE HEALTH CARE, CARBONDALE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 109 CALIFORNIA ST | ||||||||
Address2: | PO BOX 577 | ||||||||
City: | CARTERVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 629181923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6189858221 | ||||||||
FaxNumber: | 6189856860 | ||||||||
Practice Location | |||||||||
Address1: | 400 S LEWIS LN | ||||||||
Address2: |   | ||||||||
City: | CARBONDALE | ||||||||
State: | IL | ||||||||
PostalCode: | 629013547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185199900 | ||||||||
FaxNumber: | 6185291385 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2009 | ||||||||
LastUpdateDate: | 12/23/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JENSEN | ||||||||
AuthorizedOfficialFirstName: | PATSY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6189858221 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | CF3444 | 01 | IL | MEDICARE RR | OTHER |