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	124Q00000X	Dental Hygienist
2	101YM0800X	Mental Health Counselor
3	1223G0001X	General Practice Dentistry
4	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1912610965
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
Country	:	US
Telephone Number	:	618-519-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	20163 CORINTH RD
Second Line	:
City	:	PITTSBURG
State	:	IL
Zip	:	62974-1449
Country	:	US
Telephone Number	:	618-519-9200
Fax Number	:	618-988-0880

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

Provider Enumeration Date	:	01/04/2023
Last Update Date	:	04/09/2024

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