NPIMap

Organization Active NPI

Gibson Community Hospital Association

Doing business as Prairie Family Medicine and Obstetrics

  • Rural Health Clinic/Center
  • Forrest, IL
National Provider Identifier
1063462976
Registry record updated Feb 4, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
GIBSON COMMUNITY HOSPITAL ASSOCIATION
Doing business as
Prairie Family Medicine and Obstetrics
Practice address
122 E Wabash Ave
Forrest, IL 61741-9369
Phone
(815) 657-8707
Fax
(815) 657-8717
NPI assigned
May 11, 2006
Last updated
Feb 4, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
GIBSON COMMUNITY HOSPITAL ASSOCIATIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 4, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Matthew Ertel
Title
Chief Financial Officer
Phone
(217) 784-2601

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Multi-Specialty Clinic/Center 261QM1300X NU
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

122 E Wabash Ave
Forrest, IL 61741-9369

Mailing address

122 E Wabash Ave
Forrest, IL 61741-9369
Phone (815) 657-8707

Other names 1

  • Prairie Family Medicine and Obstetrics Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20040505001293 IL Part B Supplier - Clinic/Group Practice 5092703124 Receives reassigned benefits from 201 practitioners
38 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Watseka, IL; Urbana, IL; Paxton, IL; Fairbury, IL; Onarga, IL; Mahomet, IL; Hoopeston, IL; Gibson City, IL…
O20071116000131 IL Part A Provider - Critical Access Hospital 5092703124 Receives reassigned benefits from 156 practitioners
22 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Onarga, IL; Hoopeston, IL; Gibson City, IL; Forrest, IL; Cissna Park, IL
O20090902000107 IL Part A Provider - Rural Health Clinic 5092703124 Practice locations: Forrest, IL

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1063462976. Details of each certification follow.

Hospital certification: CCN 141317

Legal name
GIBSON COMMUNITY HOSPITAL ASSOCIATION
Doing business as
GIBSON AREA HOSPITAL & HEALTH SERVICES
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Jan 3, 2002
Last certification
Oct 7, 2016
Beds
25
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Incorporated
Nov 30, 1946 in IL
Enrollment address
1120 N Melvin St
Gibson City, IL 60936-1477

Rural health clinic certification: CCN 148505

Legal name
GIBSON COMMUNITY HOSPITAL ASSOCIATION
Doing business as
PRAIRIE FAMILY MEDICINE & OBSTETRICS
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 30, 2009
Last certification
Aug 21, 2020
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Nov 30, 1946 in IL
Enrollment address
122 E Wabash Ave
Forrest, IL 61741-9369
Related CCNs
141317

Facilities connected through Provider of Services related, parent or unit certification numbers.

View all 25

Other NPIs with the same Medicare PAC ID 15

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 15

Other NPIs on the same Medicare enrollment 43

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 43

Care Compare: Hospital

Medicare Care Compare
Listed as
Gibson Community HospitalCCN 141317 · All quality measures
Overall star rating
4 of 5
Type
Critical Access Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory
Part of
Gibson Area Hospital

Ownership & related parties

All disclosed owners & managing parties 22

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Robert C Schmitt Individual Corporate OfficerCeo Dec 9, 2002
W-2 Managing EmployeeCeo Dec 9, 2002
W-2 Managing EmployeeCeo Dec 9, 2002 100%
Jessica Delost Individual Corporate Officer Oct 1, 2022
W-2 Managing Employee Oct 1, 2022
Michael E Young Individual Corporate Director Nov 1, 2001
Corporate DirectorBoard Member Nov 1, 2001
Ellen M Lee Individual Corporate Director Nov 1, 1990
Corporate DirectorBoard Vice President Nov 1, 1990
Mark M Spangler Individual Corporate Director Nov 1, 2022
Justin Taylor Individual Corporate Director Mar 1, 2018
Corporate DirectorBoard Member Mar 1, 2018
Kevin D Seymour Individual Corporate Director Mar 1, 2018
Corporate DirectorBoard Member Mar 1, 2018
Kathleen J Bennett Individual Corporate Director Nov 1, 2010
Corporate DirectorBoard Member Nov 1, 2010
Donald P Reese Individual Corporate Director Feb 1, 2021
Matthew R Ertel Individual Corporate OfficerCfo Oct 1, 2016
W-2 Managing EmployeeCfo Oct 1, 2016
Robin L Rose Individual Corporate OfficerCoo/Cco Nov 15, 2004
W-2 Managing EmployeeCoo/Cco Nov 15, 2004
Corporate OfficerCoo/Cno Nov 15, 2004
W-2 Managing EmployeeCoo/Cno Nov 15, 2004
Andy Hudson Individual Corporate Officer Nov 1, 2022
Marty a Nuss Individual Corporate Director Nov 1, 2010
Corporate DirectorBoard President Nov 1, 2010
Steven P Kelly Individual Corporate Director Nov 1, 2009
Corporate DirectorBoard Member Nov 1, 2009
Brian E Steidinger Individual Corporate Director Nov 16, 2016
Corporate DirectorBoard Member Nov 16, 2016
Justin Swan Individual Corporate Director Oct 1, 2022
Mike E Petersen Individual Corporate Director Mar 1, 2018
Corporate DirectorBoard Member Mar 1, 2018
Margo C Martin Individual Corporate Director Nov 1, 1999
Corporate DirectorBoard Member Nov 1, 1999
Nancy L Krumwiede Individual Corporate DirectorBoard Secretary Nov 1, 1999
Carl E Hudson Individual Corporate DirectorBoard Member Nov 1, 1988
David J Hagan Individual Corporate DirectorBoard Member Nov 1, 1985
Teresa L Gardner Individual W-2 Managing EmployeeClinical Informatics Nurse Jan 17, 2020

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 153

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 153

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147305600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1643932800000",
    "number": "1063462976",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "122 E WABASH AVE",
            "city": "FORREST",
            "state": "IL",
            "postal_code": "617419369",
            "telephone_number": "815-657-8707",
            "fax_number": "815-657-8717"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "122 E WABASH AVE",
            "city": "FORREST",
            "state": "IL",
            "postal_code": "617419369",
            "telephone_number": "815-657-8707",
            "fax_number": "815-657-8717"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GIBSON COMMUNITY HOSPITAL ASSOCIATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "GIBSON COMMUNITY HOSPITAL ASSOCIATION",
        "enumeration_date": "2006-05-11",
        "last_updated": "2022-02-04",
        "certification_date": "2022-02-04",
        "status": "A",
        "authorized_official_last_name": "ERTEL",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "217-784-2601"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Prairie Family Medicine and Obstetrics",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Prairie Family Medicine and Obstetrics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Forrest, IL

Sources for this page

Verify at the official NPI Registry.