Provider Demographics
NPI:1154723492
Name:GIBSON COMMUNITY HOSPTIAL ASSN
Entity type:Organization
Organization Name:GIBSON COMMUNITY HOSPTIAL ASSN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:R
Authorized Official - Last Name:KESTNER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:815-657-8707
Mailing Address - Street 1:122 E WABASH AVE
Mailing Address - Street 2:P O BOX 58
Mailing Address - City:FORREST
Mailing Address - State:IL
Mailing Address - Zip Code:61741-9369
Mailing Address - Country:US
Mailing Address - Phone:815-657-8707
Mailing Address - Fax:815-657-8717
Practice Address - Street 1:122 E WABASH AVE
Practice Address - Street 2:
Practice Address - City:FORREST
Practice Address - State:IL
Practice Address - Zip Code:61741-9369
Practice Address - Country:US
Practice Address - Phone:815-657-8707
Practice Address - Fax:815-657-8717
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GIBSON COMMUNITY HOSPITAL ASSN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005214363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1063462976Medicaid
IL1063462976Medicaid