SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP

Provider Demographics

• NPI: 1639295314
• Name: SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
• Entity type: Organization
• Organization Name: SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP
• Authorized Official - Title/Position: CEO
• Authorized Official - First Name: CHRISTINA
• Authorized Official - Last Name: CARNEY
• 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 - 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
• Enumeration Date: 2007-03-22
• Last Update Date: 2024-04-05

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)
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	Group - Multi-Specialty

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