NPIMap

Organization Active NPI

Effingham Obstetrics and Gynecology Associates PLLC

  • Obstetrics & Gynecology Physician
  • Effingham, IL
National Provider Identifier
1649677063
Registry record updated Nov 8, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X
Legal business name
EFFINGHAM OBSTETRICS AND GYNECOLOGY ASSOCIATES PLLC
Practice address
912 N Henrietta St
Effingham, IL 62401
Phone
(217) 342-3337
Fax
(217) 347-3328
NPI assigned
Dec 1, 2014
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
Kelly Hunt Haller, M.D.NPI 1871589382
Title
Member
Phone
(217) 342-3337

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU
Obstetrics & Gynecology Physician 207V00000X NU Primary

Addresses

Primary practice location

912 N Henrietta St
Effingham, IL 62401

Mailing address

PO Box 784
Effingham, IL 62401-0784
Phone (217) 342-3337

Other identifiers 1

IdentifierTypeStateIssuer
371326540002MedicaidIL

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20150306001439 IL Part B Supplier - Clinic/Group Practice 2961726021 Receives reassigned benefits from 14 practitioners
Practice locations: Effingham, IL
O20150709000882 IL Part A Provider - Rural Health Clinic 2961726021 Practice locations: Effingham, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1649677063. Details of each certification follow.

Rural health clinic certification: CCN 783818

Legal name
EFFINGHAM OBSTETRICS AND GYNECOLOGY ASSOCIATES PLLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 28, 2010
Last certification
Jul 31, 2024
Ownership / control type
1C
Most recent change of ownership
Dec 17, 2014 (1 total)
Organization structure
LLCProprietary
Incorporated
Dec 17, 2014 in IL
Enrollment address
912N Henrietta St
Effingham, IL 62401-1788

National Provider Directory

National Provider Directory

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/29023/brand/6/csg/101/fhir/r4

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Kelly H Haller Individual 5% Or Greater Direct Ownership InterestManaging Member Jan 1, 2015 50%
Corporate Officer Jan 1, 2015 50%
Corporate Director Jan 1, 2015 50%
Operational/Managerial Control Jan 1, 2015 50%
Bonnie E Wise Individual 5% Or Greater Direct Ownership InterestManaging Member Aug 3, 2023 50%
Corporate OfficerManaging Member Aug 3, 2023 50%
Corporate DirectorManaging Member Aug 3, 2023 50%
Operational/Managerial ControlManaging Member Aug 3, 2023 50%

Owners & managing parties with NPI records 1

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

  • Kelly Hunt Haller, MD
    • Obstetrics & Gynecology Physician
    • Effingham, IL
    • NPI 1871589382

    5% Or Greater Direct Ownership Interest, Corporate Director, Corporate Officer, Operational/Managerial Control

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 17

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.

View all 17

NPI Registry JSON

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

{
    "created_epoch": "1417392000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1699401600000",
    "number": "1649677063",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 784",
            "city": "EFFINGHAM",
            "state": "IL",
            "postal_code": "624010784",
            "telephone_number": "217-342-3337",
            "fax_number": "217-347-3328"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "912 N HENRIETTA ST",
            "city": "EFFINGHAM",
            "state": "IL",
            "postal_code": "62401",
            "telephone_number": "217-342-3337",
            "fax_number": "217-347-3328"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EFFINGHAM OBSTETRICS AND GYNECOLOGY ASSOCIATES PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-01",
        "last_updated": "2023-11-08",
        "certification_date": "2023-11-08",
        "status": "A",
        "authorized_official_last_name": "HALLER",
        "authorized_official_first_name": "KELLY",
        "authorized_official_middle_name": "HUNT",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "217-342-3337",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "371326540002",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Effingham, IL

Sources for this page

Verify at the official NPI Registry.