Provider Demographics
NPI:1972926236
Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Other - Org Name:MAHOMET SPECIALTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:SCHMITT
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:217-784-2600
Mailing Address - Street 1:1504 PATTON DR
Mailing Address - Street 2:UNIT #3
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-8126
Mailing Address - Country:US
Mailing Address - Phone:217-586-2633
Mailing Address - Fax:
Practice Address - Street 1:1504 PATTON DR
Practice Address - Street 2:UNIT #3
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-8126
Practice Address - Country:US
Practice Address - Phone:217-586-2633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000836207X00000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
825130Medicare Oscar/Certification