Provider Demographics
NPI:1992041511
Name:MCDONOUGH COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:MCDONOUGH COUNTY HOSPITAL DISTRICT
Other - Org Name:BUSHNELL FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-833-4101
Mailing Address - Street 1:525 E GRANT ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 W HAIL ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:IL
Practice Address - Zip Code:61422-1346
Practice Address - Country:US
Practice Address - Phone:309-772-9444
Practice Address - Fax:309-772-9446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-31
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062336Medicaid
IL5515957OtherBLUE CROSS BLUE SHIELD OF ILLINOIS
IL148952OtherMEDICARE - RURAL HEALTH