=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114304045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GIBSON COMMUNITY HOSPITAL ASSOCIATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2015
-----------------------------------------------------
Last Update Date | 10/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 E 8TH ST
-----------------------------------------------------
City | GIBSON CITY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60936-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-784-4076
-----------------------------------------------------
Fax | 217-784-2044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 E 8TH ST
-----------------------------------------------------
City | GIBSON CITY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60936-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-784-4076
-----------------------------------------------------
Fax | 217-784-2044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF COMPLIANCE OFFICER
-----------------------------------------------------
Name | MR. MIKE MEUNIER
-----------------------------------------------------
Credential | MBA, CHC
-----------------------------------------------------
Telephone | 217-784-2286
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0000836
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------