Healthcare Provider Details

I. General information

NPI: 1972926236
Provider Name (Legal Business Name): GIBSON COMMUNITY HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 PATTON DR UNIT #3
MAHOMET IL
61853-8126
US

IV. Provider business mailing address

1504 PATTON DR UNIT #3
MAHOMET IL
61853-8126
US

V. Phone/Fax

Practice location:
  • Phone: 217-586-2633
  • Fax:
Mailing address:
  • Phone: 217-586-2633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0000836
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number0000836
License Number StateIL

VIII. Authorized Official

Name: ROBERT C SCHMITT II
Title or Position: CEO
Credential:
Phone: 217-784-2600