NPIMap

Organization Active NPI

Mason Hospital District

Doing business as Manito Medical Associates

  • Rural Health Clinic/Center
  • Manito, IL
National Provider Identifier
1780128512
Registry record updated Dec 14, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MASON HOSPITAL DISTRICT
Doing business as
Manito Medical Associates
Practice address
1301 S East Ave
Manito, IL 61546
Phone
(309) 968-5311
NPI assigned
Dec 13, 2016
Last updated
Dec 14, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 14, 2016

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

Authorized official

Name
Mary Layton
Title
Director of Clinic Operations
Phone
(309) 543-6600

Specialties & licenses 1

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

Addresses

Primary practice location

1301 S East Ave
Manito, IL 61546

Mailing address

PO Box 530
Havana, IL 62644-0530
Phone (309) 543-6600

Other names 1

  • Manito Medical Associates Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170320001286 IL Part A Provider - Rural Health Clinic 2466360607 Practice locations: Manito, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1780128512. Details of each certification follow.

Rural health clinic certification: CCN 148592

Legal name
MASON HOSPITAL DISTRICT
Doing business as
MANITO MEDICAL ASSOCIATES
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 19, 2018
Last certification
Apr 19, 2018
Ownership / control type
Non-profit – church related
Organization structure
GovernmentNon-profit
Incorporated
Oct 17, 1957 in IL
Enrollment address
1301 S East Ave
Manito, IL 61546-8909
Related CCNs
141313

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

Other NPIs with the same Medicare PAC ID 4

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

National Provider Directory

National Provider Directory
Tax ID family
Mason Dist Hosp Ekg9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

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

Locations

1301 S East Ave
Manito, IL 61546
Phone (309) 968-5311

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Randall R Fornoff Individual Corporate OfficerVice Chairman Apr 12, 2004
Denis Bryant Individual Corporate OfficerChairman Aug 3, 2013
Mason Hospital District Organization, Havana, IL Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 2017 100%
Carol Himmel Individual Corporate OfficerOfficer Oct 1, 2023
Marty Balbinot Individual Corporate OfficerSecretary Sep 30, 2015
Linda Leach Individual Corporate Officer Oct 1, 2021
Daniel Gunter Individual Corporate Officer Oct 1, 2023
Douglas Kosier Individual Corporate OfficerCeo of the Facility Sep 1, 2018 100%
W-2 Managing EmployeeCeo of the Facility Sep 1, 2017 100%
Alan Tucker Individual Corporate Officer Oct 1, 2022
Megan Weaver Individual W-2 Managing Employee Jan 8, 2020
Operational/Managerial Control Jan 8, 2020
Daniel Houghton Individual Corporate DirectorDirector Jan 19, 2005
William R Blessman Individual Corporate DirectorDirector Apr 12, 2004

Owners & managing parties with NPI records 4

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

All facility ownership & control disclosures 4

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

FacilityTypeRoleSince
Mason District HospitalHavana, IL, CCN 141313 Hospital 5% Or Greater Direct Ownership Interest (100%) Apr 23, 2014
Mason District HospitalHavana, IL, CCN 14Z313 Hospital 5% Or Greater Direct Ownership Interest (100%) Oct 1, 2011
Mason District Hospital Home HealthHavana, IL, CCN 147202 Home health agency 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Jan 1, 1966
Dec 29, 2009
Havana Medical AssociatesHavana, IL, CCN 143457 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Feb 1, 2001

Owned or controlled facilities with NPI records 5

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

Facilities with the same owner 3

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

Practitioners & affiliated clinicians

Practitioners 18

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 18

NPI Registry JSON

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

{
    "created_epoch": "1481587200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1481673600000",
    "number": "1780128512",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 530",
            "city": "HAVANA",
            "state": "IL",
            "postal_code": "626440530",
            "telephone_number": "309-543-6600"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1301 S EAST AVE",
            "city": "MANITO",
            "state": "IL",
            "postal_code": "61546",
            "telephone_number": "309-968-5311"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MASON HOSPITAL DISTRICT",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-12-13",
        "last_updated": "2016-12-14",
        "status": "A",
        "authorized_official_last_name": "LAYTON",
        "authorized_official_first_name": "MARY",
        "authorized_official_title_or_position": "DIRECTOR OF CLINIC OPERATIONS",
        "authorized_official_telephone_number": "309-543-6600"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Manito Medical Associates",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Manito, IL

Sources for this page

Verify at the official NPI Registry.