NPIMap

Organization Active NPI

McDonough County Hospital District

Doing business as MDH Pediatric Clinic

  • Rural Health Clinic/Center
  • Macomb, IL
National Provider Identifier
1770100414
Registry record updated Jun 29, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MCDONOUGH COUNTY HOSPITAL DISTRICT
Doing business as
MDH Pediatric Clinic
Practice address
505 E Grant St Ste 202
Macomb, IL 61455-3373
Phone
(309) 833-1729
Fax
(309) 836-1779
NPI assigned
Jun 29, 2020
Last updated
Jun 29, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 29, 2020

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

Authorized official

Name
William Murdock
Title
Cfo
Phone
(563) 244-3511

Specialties & licenses 1

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

Addresses

Primary practice location

505 E Grant St Ste 202
Macomb, IL 61455-3373

Mailing address

PO Box 1179
Macomb, IL 61455-5579
Phone (309) 836-1524

Other names 1

  • MDH Pediatric Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200715003325 IL Part A Provider - Rural Health Clinic 0446140180 Practice locations: Macomb, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1770100414. Details of each certification follow.

Rural health clinic certification: CCN 148617

Legal name
MCDONOUGH COUNTY HOSPITAL DISTRICT
Doing business as
MDH PEDIATRIC CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 3, 2020
Last certification
Nov 3, 2020
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
515 E Grant St
Ste 111
Macomb, IL 61455-3315
Related CCNs
140089

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

Other NPIs with the same Medicare PAC ID 10

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

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
14D2021862MDH Pediatric Clinic515 E Grant St, Ste 111, Macomb, IL 61455Certificate of waiverMar 22, 2027

National Provider Directory

National Provider Directory
Tax ID family
McDonough Dist Hospital20 organizations share this tax ID, including this one

Other organizations with this tax ID 19

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

View all 19

Locations

515 E Grant St
Ste 111
Macomb, IL 61455
Phone (309) 833-1729

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
McDonough County Hospital District Organization, Macomb, IL 5% Or Greater Direct Ownership Interest Jul 1, 2020 100%
Sherri L Hitchcock Individual Corporate OfficerCfo Feb 1, 2025
W-2 Managing EmployeeCfo Feb 1, 2025
William R Murdock Individual Corporate OfficerP Apr 22, 2019
W-2 Managing EmployeePresident & Ceo Apr 22, 2019

Owners & managing parties with NPI records 10

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

All facility ownership & control disclosures 6

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
McDonough District HospitalMacomb, IL, CCN 140089 Hospital 5% Or Greater Direct Ownership Interest (100%) Sep 30, 2018
McDonough District HospitalMacomb, IL, CCN 14U089 Hospital 5% Or Greater Direct Ownership Interest (100%) Jun 10, 2014
McDonough District Hospital Home HealthMacomb, IL, CCN 147293 Home health agency Operational/Managerial Control (100%) Oct 22, 2012
McDonough District HospitalMacomb, IL, CCN 141524 Hospice 5% Or Greater Direct Ownership Interest (100%) Jan 12, 1989
Bushnell Family PracticeBushnell, IL, CCN 148522 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Feb 1, 2013
MDH Family Medicine/Convenience Care/Surgery/ENT ClinicMacomb, IL, CCN 148619 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2020

Owned or controlled facilities with NPI records 6

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 6

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 1

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": "1593388800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1593388800000",
    "number": "1770100414",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1179",
            "city": "MACOMB",
            "state": "IL",
            "postal_code": "614555579",
            "telephone_number": "309-836-1524",
            "fax_number": "309-836-1525"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "505 E GRANT ST STE 202",
            "city": "MACOMB",
            "state": "IL",
            "postal_code": "614553373",
            "telephone_number": "309-833-1729",
            "fax_number": "309-836-1779"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCDONOUGH COUNTY HOSPITAL DISTRICT",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-06-29",
        "last_updated": "2020-06-29",
        "certification_date": "2020-06-29",
        "status": "A",
        "authorized_official_last_name": "MURDOCK",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "563-244-3511"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MDH Pediatric Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "MDH Pediatric Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Macomb, IL

Sources for this page

Verify at the official NPI Registry.