Basic Information
| Provider Information | |||||||||
| NPI: | 1245260645 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP | ||||||||
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| OtherOrganizationName: | SHAWNEE HEALTH CARE, MURPHYSBORO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 577 | ||||||||
| Address2: | 109 CALIFORNIA STREET | ||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629180577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189858221 | ||||||||
| FaxNumber: | 6189856860 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 SOUTH HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | MURPHYSBORO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629663333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186873418 | ||||||||
| FaxNumber: | 6186871859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| 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 | 207Q00000X | N | 193400000X SINGLE 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 | 10032052 | 01 | IL | BCBS | OTHER |