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  5. HSHS GOOD SHEPHERD HOSPITAL, INC.

HSHS GOOD SHEPHERD HOSPITAL, INC.

Company Details

Entity Name: HSHS GOOD SHEPHERD HOSPITAL, INC.
Jurisdiction: Illinois
Entity Type: Corporation - Not-for-Profit
Status: Goodstanding
Date Formed: 12 Jun 1916
Company Number: CORP_13790248
File Number: 13790248
Place of Formation: ILLINOIS

Unique Entity ID

Unique Entity ID Expiration Date Physical Address Mailing Address
HFVALAJLM8A3 2023-11-22 200 S CEDAR ST, SHELBYVILLE, IL, 62565, 1838, USA 200 S CEDAR ST, SHELBYVILLE, IL, 62565, 1838, USA

Business Information
Doing Business As SHELBY MEMORIAL HOSPITAL
Division Name HSHS GOOD SHEPHERD HOSPITAL INC
Congressional District 15
State/Country of Incorporation IL, USA
Activation Date 2022-11-24
Initial Registration Date 2014-06-16
Entity Start Date 1916-05-23
Fiscal Year End Close Date Jun 30

Points of Contacts
Electronic Business
Title PRIMARY POC
Name ADAM FERIOZZI
Role MR.
Address 200 S CEDAR STREET, SHELBYVILLE, IL, 62565, USA
Government Business
Title PRIMARY POC
Name ROBERT SEIPEL
Role MR.
Address 200 S CEDAR STREET, SHELBYVILLE, IL, 62565, USA
Past Performance
Title ALTERNATE POC
Name DAVID MORTIMER
Address 200 S CEDAR STREET, SHELBYVILLE, IL, 62565, USA

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
SHELBY MEMORIAL HOSPITAL PENSION PLAN 2022 370512290 2023-06-14 HSHS GOOD SHEPHERD HOSPITAL 88
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1969-03-01
Business code 622000
Sponsor’s telephone number 2177743961
Plan sponsor’s address 200 SOUTH CEDAR STREET, SHELBYVILLE, IL, 62565

Signature of
Role Plan administrator
Date 2023-06-14
Name of individual signing CASSIE FRYE
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2023-06-14
Name of individual signing CASSIE FRYE
Valid signature Filed with authorized/valid electronic signature
SHELBY MEMORIAL HOSPITAL EMPLOYEE HEALTH PLAN 2021 370512290 2023-12-29 HSHS GOOD SHEPHERD HOSPITAL 89
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1985-01-01
Business code 622000
Sponsor’s telephone number 2177743961
Plan sponsor’s address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838

Signature of
Role Plan administrator
Date 2023-12-29
Name of individual signing ADAM FERIOZZI
Valid signature Filed with authorized/valid electronic signature
SHELBY MEMORIAL HOSPITAL EMPLOYEE HEALTH PLAN 2020 370512290 2023-12-29 HSHS GOOD SHEPHERD HOSPITAL 81
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1985-01-01
Business code 622000
Sponsor’s telephone number 2177743961
Plan sponsor’s mailing address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838
Plan sponsor’s address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838

Number of participants as of the end of the plan year
Active participants 89

Signature of
Role Plan administrator
Date 2023-12-29
Name of individual signing ADAM FERIOZZI
Valid signature Filed with authorized/valid electronic signature
SHELBY MEMORIAL HOSPITAL EMPLOYEE HEALTH PLAN 2020 370512290 2021-10-15 HSHS GOOD SHEPHERD HOSPITAL 81
Three-digit plan number (PN) 502
Effective date of plan 1985-01-01
Business code 622000
Sponsor’s telephone number 2177743961
Plan sponsor’s mailing address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838
Plan sponsor’s address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838

Number of participants as of the end of the plan year
Active participants 89

Signature of
Role Plan administrator
Date 2021-10-15
Name of individual signing ADAM FERIOZZI
Valid signature Filed with authorized/valid electronic signature
SHELBY MEMORIAL HOSPITAL EMPLOYEE HEALTH PLAN 2019 370512290 2020-11-13 HSHS GOOD SHEPHERD HOSPITAL 88
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1985-01-01
Business code 622000
Sponsor’s telephone number 2177743961
Plan sponsor’s mailing address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838
Plan sponsor’s address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838

Number of participants as of the end of the plan year
Active participants 99

Signature of
Role Plan administrator
Date 2020-11-13
Name of individual signing AARON PUCHBAUER
Valid signature Filed with authorized/valid electronic signature
SHELBY MEMORIAL HOSPITAL EMPLOYEE DISABILITY 2019 370512290 2020-11-13 HSHS GOOD SHEPHERD HOSPITAL 81
File View Page
Three-digit plan number (PN) 506
Effective date of plan 1988-01-01
Business code 622000
Sponsor’s telephone number 2177743961
Plan sponsor’s mailing address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838
Plan sponsor’s address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838

Number of participants as of the end of the plan year
Active participants 89

Signature of
Role Plan administrator
Date 2020-11-13
Name of individual signing AARON PUCHBAUER
Valid signature Filed with authorized/valid electronic signature
SHELBY MEMORIAL HOSPITAL EMPLOYEE HEALTH PLAN 2019 370512290 2020-10-14 HSHS GOOD SHEPHERD HOSPITAL 88
Three-digit plan number (PN) 502
Effective date of plan 1985-01-01
Business code 622000
Sponsor’s telephone number 2177743961
Plan sponsor’s mailing address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838
Plan sponsor’s address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838

Number of participants as of the end of the plan year
Active participants 99

Signature of
Role Plan administrator
Date 2020-10-14
Name of individual signing AARON PUCHBAUER
Valid signature Filed with authorized/valid electronic signature
SHELBY MEMORIAL HOSPITAL EMPLOYEE DISABILITY 2019 370512290 2020-10-14 HSHS GOOD SHEPHERD HOSPITAL 81
Three-digit plan number (PN) 506
Effective date of plan 1988-01-01
Business code 622000
Sponsor’s telephone number 2177743961
Plan sponsor’s mailing address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838
Plan sponsor’s address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838

Number of participants as of the end of the plan year
Active participants 89

Signature of
Role Plan administrator
Date 2020-10-14
Name of individual signing AARON PUCHBAUER
Valid signature Filed with authorized/valid electronic signature
SMH EMPLOYEE GROUP LIFE PLAN 2019 370512290 2020-10-12 HSHS GOOD SHEPHERD HOSPITAL 96
File View Page
Three-digit plan number (PN) 503
Effective date of plan 1985-01-01
Business code 622000
Sponsor’s telephone number 2177743961
Plan sponsor’s mailing address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838
Plan sponsor’s address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838

Number of participants as of the end of the plan year
Active participants 98

Signature of
Role Plan administrator
Date 2020-10-12
Name of individual signing AARON PUCHBAUER
Valid signature Filed with authorized/valid electronic signature
SMH GROUP LONG TERM DISABILITY 2019 370512290 2020-10-12 HSHS GOOD SHEPHERD HOSPITAL 80
File View Page
Three-digit plan number (PN) 509
Effective date of plan 1993-01-01
Business code 622000
Sponsor’s telephone number 2177743961
Plan sponsor’s mailing address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838
Plan sponsor’s address 200 S CEDAR ST, SHELBYVILLE, IL, 625651838

Number of participants as of the end of the plan year
Active participants 88

Signature of
Role Plan administrator
Date 2020-10-12
Name of individual signing AARON PUCHBAUER
Valid signature Filed with authorized/valid electronic signature

Agent

Name and Address Role Appointment Date
PAIGE M. TOTH, 4936 LAVERNA RD, SPRINGFIELD, 62707, SANGAMON Agent 2022-12-05

License

License Type License Number Status License Code License Description Business Activity Date Issued Effective Date Expiration Date
HME AND SERVICES PROV 203001888 No data No data HOME MEDICAL EQUIPMENT AND SERVICES PROVIDER No data 2017-01-18 2018-04-13 2021-03-31

Historical Names

Name Change Date
SHELBY MEMORIAL HOSPITAL ASSOCIATION, INC. 2017-01-13
SHELBY COUNTY MEMORIAL HOSPITAL ASSOCIATION 1981-01-27

Related by officers

PAIGE M. TOTH, 4936 LAVERNA RD, SPRINGFIELD, 62707, SANGAMON

ST. ELIZABETH'S HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS ST. ANTHONY'S MEMORIAL HOSPITAL, OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS ST. FRANCIS HOSPITAL, OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS ST. JOHN'S HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS ST. JOSEPH'S HOSPITAL, OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS ST. MARY'S HOSPITAL, DECATUR, OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS HSHS HOLY FAMILY HOSPITAL, INC. UTLAUT MEMORIAL FOUNDATION, INC. ST. JOSEPH'S HOSPITAL, BREESE, OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS PRAIRIE HEART INSTITUTE MANAGEMENT COMPANY, LLC

Related by address

No related companies by address

Date of last update: 13 Jan 2025

Sources: Illinois Office of the Secretary of State

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