Provider Demographics
NPI:1548544679
Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Entity type:Organization
Organization Name:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
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:217-784-2600
Mailing Address - Street 1:221 WAL CREST DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739-8998
Mailing Address - Country:US
Mailing Address - Phone:815-692-1150
Mailing Address - Fax:815-692-1153
Practice Address - Street 1:221 WAL CREST DR
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739-8998
Practice Address - Country:US
Practice Address - Phone:815-692-1150
Practice Address - Fax:815-692-1153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2023-11-08
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
IL825130OtherMEDICARE PTAN