NPIMap

Organization Active NPI

Graham Hospital Association

Doing business as Graham Convenient Care

  • Urgent Care Clinic/Center
  • Canton, IL
National Provider Identifier
1124735402
Registry record updated Mar 27, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Urgent Care Clinic/CenterTaxonomy code 261QU0200X
Legal business name
GRAHAM HOSPITAL ASSOCIATION
Doing business as
Graham Convenient Care
Practice address
126 N 5TH Ave
Canton, IL 61520-1654
Phone
(309) 647-0201
NPI assigned
Nov 4, 2022
Last updated
Mar 27, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 27, 2023

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

Authorized official

Name
Miss Paige Fahnestock
Title
Credentialing Specialist
Phone
(309) 647-5240

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X NU
Urgent Care Clinic/Center 261QU0200X NU Primary

Addresses

Primary practice location

126 N 5TH Ave
Canton, IL 61520-1654

Mailing address

126 N 5TH Ave
Canton, IL 61520-1654

Other names 1

  • Graham Convenient Care Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040510000873 IL Part B Supplier - Clinic/Group Practice 2769375021 Receives reassigned benefits from 139 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Galesburg, IL; Williamsfield, IL; Macomb, IL; Lewistown, IL; Glasford, IL; Farmington, IL; Elmwood, IL; Canton, IL
O20230425001534 IL Part A Provider - Rural Health Clinic 2769375021 Practice locations: Canton, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124735402. Details of each certification follow.

Rural health clinic certification: CCN 148661

Legal name
GRAHAM HOSPITAL ASSOCIATION
Doing business as
GMG CONVENIENT CARE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 19, 2024
Last certification
Feb 19, 2024
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Nov 21, 1905 in IL
Enrollment address
126 N 5TH Ave
Canton, IL 61520-2800
Related CCNs
140001

Other NPIs with the same Medicare PAC ID 14

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

View all 14

Other NPIs on the same Medicare enrollment 13

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

View all 13

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D2281372Graham Medical Group - Convenient Care126 N Fifth Ave, Canton, IL 61520Certificate of waiverMay 4, 2027

National Provider Directory

National Provider Directory
Tax ID family
Graham Hospital22 organizations share this tax ID, including this one

Other organizations with this tax ID 21

Organizations that report the same tax identification number in the National Provider Directory.

View all 21

Locations

125 N 5th Ave
Canton, IL 61520

2028 N Seminary St
Galesburg, IL 61401
Phone (309) 342-5166

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Allison Sours Individual Corporate OfficerPresident and Ceo Jan 6, 2026
W-2 Managing EmployeePresident & Ceo Jan 5, 2026
Operational/Managerial ControlPresident & Ceo Jan 5, 2026
Morris D Lee Individual Corporate DirectorBoard Member Jan 1, 2020
William Carlberg Individual Corporate DirectorBoard Member Jan 1, 2020
Kenneth Krock Individual Corporate DirectorBoard Member Jan 1, 2021
Terry Moss Individual Corporate Director Jan 1, 2020
Janis Blout Individual Corporate DirectorBoard Member Jan 1, 2020
Anne Hollis Individual Corporate DirectorBoard Member Jan 1, 2020
Erin Elizabeth Bailey Individual Corporate DirectorBoard Member Jul 1, 2025
Kevin Meade Individual Corporate DirectorBoard Member Jan 1, 2020
Sarah Keefer Individual Corporate DirectorBoard Member Jul 1, 2025
Julie Reeder Individual Corporate Officer Mar 6, 2017
W-2 Managing Employee Mar 17, 2017

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 10

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.

NPI Registry JSON

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

{
    "created_epoch": "1667520000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1679875200000",
    "number": "1124735402",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "126 N 5TH AVE",
            "city": "CANTON",
            "state": "IL",
            "postal_code": "615201654"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "126 N 5TH AVE",
            "city": "CANTON",
            "state": "IL",
            "postal_code": "615201654",
            "telephone_number": "309-647-0201"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAHAM HOSPITAL ASSOCIATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-11-04",
        "last_updated": "2023-03-27",
        "certification_date": "2023-03-27",
        "status": "A",
        "authorized_official_last_name": "FAHNESTOCK",
        "authorized_official_first_name": "PAIGE",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "309-647-5240",
        "authorized_official_name_prefix": "Miss"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QU0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Urgent Care",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Graham Convenient Care",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Graham Convenient Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Canton, IL

Sources for this page

Verify at the official NPI Registry.