MEDICARE: SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker
3	1223G0001X	General Practice Dentistry
4	124Q00000X	Dental Hygienist
5	207Q00000X	Family Medicine Physician
6	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1841757242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP

Provider Business Mailing Address
First Line	:	109 CALIFORNIA ST
Second Line	:	PO BOX 577
City	:	CARTERVILLE
State	:	IL
Zip	:	62918-0577
Country	:	US
Telephone Number	:	618-985-8221
Fax Number	:	618-985-6860

Provider Business Practice Location Address
First Line	:	1150 E GRAND AVE RM 127
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62901-3422
Country	:	US
Telephone Number	:	618-519-9200
Fax Number	:	618-457-8931

Authorized Official
Title or Position	:	CEO
Name	:	CHRISTINA CARNEY
Credential	:
Telephone Number	:	618-956-9521

Provider Enumeration Date	:	02/22/2019
Last Update Date	:	07/16/2024

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