Rural Health Clinic of Moultrie County LLC

Key facts

NPI: 1831361344
Entity type: Organization (NPI type 2)
Primary specialty: Family Medicine Physician 207Q00000X
Legal business name: RURAL HEALTH CLINIC OF MOULTRIE COUNTY LLC
Practice address: 2 W Adams
Sullivan, IL 61951-1943
Phone: (217) 728-7353
Fax: (217) 728-2580
NPI assigned: Mar 25, 2008
Organization subpart: No

Authorized official

Name: Faisal Bukhari, M.D.
Title: Physician/Owner
Phone: (217) 728-7353

Owners & managing parties with NPI records 1

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

Faisal Bukhari, MD SC Internal Medicine Physician · Sullivan, IL · NPI 1376545509

CMS ownership 5% OR GREATER DIRECT OWNERSHIP INTEREST

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Faisal Bukhari, MD SC Internal Medicine Physician · Sullivan, IL · NPI 1376545509

NPD
Whitney Kauffman, PA Medical Physician Assistant · Champaign, IL · NPI 1043593262

NPD

Medicare participation

Medicare fee-for-service enrollment: Enrolled in IL

Rural health clinic certification: CCN 143847

Legal name: RURAL HEALTH CLINIC OF MOULTRIE COUNTY LLC
Doing business as: RURAL HEALTH CLINIC OF MOULTRIE COUNTY, LLC
Certification status: Active
Provider type (POS): Rural health clinic
Participating since: Jun 30, 1993
Last certification: Jan 19, 2021
Ownership / control type: 2B
Most recent change of ownership: Nov 3, 2013 (3 total)
Organization structure: LLC · Proprietary
Enrollment address: 2W Adams St
Sullivan, IL 61951-1943

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.

Name	Role	Since	Share
Rural Health Clinic of Moultrie County LLC Organization · Sullivan, IL LLC	5% Or Greater Direct Ownership Interest	Nov 3, 2013	100%
Faisal Bukhari Individual	5% Or Greater Direct Ownership Interest Owner/MD/President	Nov 3, 2013	100%
Karen Sims Individual	W-2 Managing Employee Practice Manager	Apr 1, 2009

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
O20140116000168	IL	Part a Provider - Rural Health Clinic	6103051024	Practice locations: Sullivan, IL

National Provider Directory

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Family Medicine Physician Group: 193200000X MULTI-SPECIALTY GROUP	207Q00000X			Yes

Addresses

Primary practice location

2 W Adams
Sullivan, IL 61951-1943

Mailing address

2 W Adams
Sullivan, IL 61951-1943
Phone (217) 728-7353

Other providers in Sullivan, IL

All providers in Sullivan, IL · Family Medicine Physician in Illinois

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 29, 2024. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
Provider of Services files (CMS): certification status, beds and related CCNs.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.