NPIMap

Organization Active NPI

Gibson Community Hospital Association

Doing business as Family Healthcare of Fairbury

  • Family Medicine Physician
  • Fairbury, IL
National Provider Identifier
1548544679
Registry record updated Nov 8, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
0000836 Issued in IL
Legal business name
GIBSON COMMUNITY HOSPITAL ASSOCIATION
Doing business as
Family Healthcare of Fairbury
Practice address
221 Wal Crest Dr
Fairbury, IL 61739-8998
Phone
(815) 692-1150
Fax
(815) 692-1153
NPI assigned
Oct 7, 2011
Last updated
Nov 8, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 8, 2023

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

Authorized official

Name
Matthew Ertel
Title
Cfo
Phone
(217) 784-2600

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X 0000836 IL Primary

Addresses

Primary practice location

221 Wal Crest Dr
Fairbury, IL 61739-8998

Mailing address

221 Wal Crest Dr
Fairbury, IL 61739-8998
Phone (815) 692-1150

Other identifiers 1

IdentifierTypeStateIssuer
825130OtherILMEDICARE PTAN

Other names 1

  • Family Healthcare of Fairbury Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

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…

Other NPIs on the same Medicare enrollment 38

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

View all 38

National Provider Directory

National Provider Directory
Tax ID family
Gibson Community Hospital43 organizations share this tax ID, including this one

Other organizations with this tax ID 42

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

View all 42

Practitioners & affiliated clinicians

Practitioners 6

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": "1317945600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1699401600000",
    "number": "1548544679",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "221 WAL CREST DR",
            "city": "FAIRBURY",
            "state": "IL",
            "postal_code": "617398998",
            "telephone_number": "815-692-1150",
            "fax_number": "815-692-1153"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "221 WAL CREST DR",
            "city": "FAIRBURY",
            "state": "IL",
            "postal_code": "617398998",
            "telephone_number": "815-692-1150",
            "fax_number": "815-692-1153"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GIBSON COMMUNITY HOSPITAL ASSOCIATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-10-07",
        "last_updated": "2023-11-08",
        "certification_date": "2023-11-08",
        "status": "A",
        "authorized_official_last_name": "ERTEL",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "217-784-2600"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "0000836",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "825130",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Family Healthcare of Fairbury",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Family Healthcare of Fairbury",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fairbury, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 8, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.