Provider Demographics
NPI:1114304045
Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Other - Org Name:GIBSON AREA FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MEUNIER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CHC
Authorized Official - Phone:217-784-2286
Mailing Address - Street 1:201 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1422
Mailing Address - Country:US
Mailing Address - Phone:217-784-4076
Mailing Address - Fax:217-784-2044
Practice Address - Street 1:201 E 8TH ST
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-1422
Practice Address - Country:US
Practice Address - Phone:217-784-4076
Practice Address - Fax:217-784-2044
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-29
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL825130Medicare PIN