Provider Demographics
NPI:1881676005
Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Other - Org Name:FAMILY HEALTHCARE OF HOOPESTON
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 1:705 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:HOOPESTON
Mailing Address - State:IL
Mailing Address - Zip Code:60942-1904
Mailing Address - Country:US
Mailing Address - Phone:217-283-5530
Mailing Address - Fax:217-283-6437
Practice Address - Street 1:705 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOOPESTON
Practice Address - State:IL
Practice Address - Zip Code:60942-1904
Practice Address - Country:US
Practice Address - Phone:217-283-5530
Practice Address - Fax:217-283-6437
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-15
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X, 261QR1300X
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047693Medicaid
D09959Medicare UPIN
211492Medicare ID - Type Unspecified
ILD09959Medicare UPIN