Provider Demographics
NPI:1023218534
Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Other - Org Name:THE ONARGA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-268-4840
Mailing Address - Street 1:109 N CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:ONARGA
Mailing Address - State:IL
Mailing Address - Zip Code:60955-1255
Mailing Address - Country:US
Mailing Address - Phone:815-268-4841
Mailing Address - Fax:815-268-4845
Practice Address - Street 1:109 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ONARGA
Practice Address - State:IL
Practice Address - Zip Code:60955-1255
Practice Address - Country:US
Practice Address - Phone:815-268-4841
Practice Address - Fax:815-268-4845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208576OtherMEDICARE GROUP