Provider Demographics
NPI:1790913903
Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Other - Org Name:D/B/A FAMILY HEALTH CLINIC OF FARMER CITY
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 1:1230 GEORGE ROCK DR
Mailing Address - Street 2:
Mailing Address - City:FARMER CITY
Mailing Address - State:IL
Mailing Address - Zip Code:61842-9488
Mailing Address - Country:US
Mailing Address - Phone:309-928-9192
Mailing Address - Fax:309-928-5316
Practice Address - Street 1:1230 GEORGE ROCK DR
Practice Address - Street 2:
Practice Address - City:FARMER CITY
Practice Address - State:IL
Practice Address - Zip Code:61842-9488
Practice Address - Country:US
Practice Address - Phone:309-928-9192
Practice Address - Fax:309-928-5316
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-25
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL148517Medicare Oscar/Certification