Basic Information
| Provider Information | |||||||||
| NPI: | 1174859870 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHAWNEE HEALTH SERVICE & DEVELOPMENT CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHAWNEE HEALTH CARE, CARBONDALE DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 CALIFORNIA ST | ||||||||
| Address2: | PO BOX 577 | ||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629181923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189858221 | ||||||||
| FaxNumber: | 6189971214 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 S. LEWIS LANE | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185199901 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2009 | ||||||||
| LastUpdateDate: | 12/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | PATSY | ||||||||
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| AuthorizedOfficialTitleorPosition: | C. E. O. | ||||||||
| AuthorizedOfficialTelephone: | 6189858221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 124Q00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Hygienist | 126800000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Assistant | 1223P0221X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 019028089 | 05 | IL | MEDICAID | 019027984 | 05 | IL | MEDICAID | 019028149 | 05 | IL | MEDICAID | 019028752 | 05 | IL | MEDICAID | 019028085 | 05 | IL | MEDICAID | 019028144 | 05 | IL | MEDICAID |