Mid-Illinois Medical Care Associates, LLC

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

License

036120332 Issued in IL

Legal business name

MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC

Doing business as

Dieterich Community Medical Center

Practice address

203 S. Main St.
Dieterich, IL 62424

Phone

(217) 925-5730

Fax

(217) 925-5736

NPI assigned

Aug 27, 2008

Last updated

Jun 27, 2017By the provider in NPPES

Organization subpart

Yes

Parent organization

MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLCAs reported in NPPES

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

Authorized official

Name

Dr. Eugene P. Dust, M.D.

Title

President of Mid-Illinois Medical C

Phone

(217) 347-2707

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Dieterich Community Medical Center Doing business as

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Part of

Mid-Illinois Medical Ca

Change-of-ownership history 1

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

• HSHS Prairie, Inc

  dba HSHS Medical Group Family Medicine - Dieterich

  • Rural Health Clinic/Center
  • Dieterich, IL
  • NPI 1033841192

  Sold to, 2022-06-30

  CMS change of ownership

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

{
    "created_epoch": "1219795200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1498521600000",
    "number": "1568619088",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1207 NETWORK CENTRE DR",
            "address_2": "SUITE 3",
            "city": "EFFINGHAM",
            "state": "IL",
            "postal_code": "624014632",
            "telephone_number": "217-347-2707",
            "fax_number": "217-347-2827"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "203 S. MAIN ST.",
            "city": "DIETERICH",
            "state": "IL",
            "postal_code": "62424",
            "telephone_number": "217-925-5730",
            "fax_number": "217-925-5736"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MID-ILLINOIS MEDICAL CARE ASSOCIATES, LLC",
        "enumeration_date": "2008-08-27",
        "last_updated": "2017-06-27",
        "status": "A",
        "authorized_official_last_name": "DUST",
        "authorized_official_first_name": "EUGENE",
        "authorized_official_middle_name": "P.",
        "authorized_official_title_or_position": "PRESIDENT OF MID-ILLINOIS MEDICAL C",
        "authorized_official_telephone_number": "217-347-2707",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "IL",
            "license": "036120332",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036120332",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dieterich Community Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jennifer Elizabeth Kistner, FNP
• Debra Kitten
• Angela Koester, COTA/L
• Morgan Rae Lidy
• Julie Marie Loy, M.A. CCC/SLP
• Morgan Michelle Repking
• Michelle Schnepper
• Stephanie Shadle
• Jennifer J Tinsley, APRN, PMHNP-BC
• Traci Walk

• Rural Health Clinic/Center in Dieterich, IL
• Providers in Dieterich, IL by specialty
• Rural Health Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 27, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.