Provider Demographics
NPI:1063462976
Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Other - Org Name:PRAIRIE FAMILY MEDICINE AND OBSTETRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:ERTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-784-2601
Mailing Address - Street 1:122 E WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:FORREST
Mailing Address - State:IL
Mailing Address - Zip Code:61741-9369
Mailing Address - Country:US
Mailing Address - Phone:815-657-8707
Mailing Address - Fax:815-657-8717
Practice Address - Street 1:122 E WABASH AVE
Practice Address - Street 2:
Practice Address - City:FORREST
Practice Address - State:IL
Practice Address - Zip Code:61741-9369
Practice Address - Country:US
Practice Address - Phone:815-657-8707
Practice Address - Fax:815-657-8717
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213763Medicare Oscar/Certification
IL148903Medicare Oscar/Certification
IL148505Medicare Oscar/Certification