Provider Demographics
NPI:1386903946
Name:GIBSON CITY CLINIC SC
Entity type:Organization
Organization Name:GIBSON CITY CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-784-8148
Mailing Address - Street 1:222 N SANGAMON AVE
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1345
Mailing Address - Country:US
Mailing Address - Phone:217-784-8148
Mailing Address - Fax:217-784-8160
Practice Address - Street 1:222 N SANGAMON AVE
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-1345
Practice Address - Country:US
Practice Address - Phone:217-784-8148
Practice Address - Fax:217-784-8160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-066538261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========-60936-02Medicaid