Unknown Individual – Family Medicine Physician, NPI 1053315812

Unknown Individual is a healthcare provider. based in Mt zion, Illinois. specializing in Family Medicine Physician. They hold a License No. 036071171 (IL). The NPI Number for Unknown Individual is 1053315812

Main info

Organization
Inactive
42 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1053315812
Phone
(217) 864-5531
Address
1200 N STATE HIGHWAY 121
Deactivation Date
22 July 2023

Doctor Profile

Medical School Name
UNIVERSITY OF MISSOURI, KANSAS CITY, SCHOOL OF MEDICINE
Secondary Phone
2178765320
Graduation Year
1984 (42 years ago)
PAC ID
9537218052
Group Practice PAC ID
6204731144
Professional Enrollment ID
I20090512000525
Data current as of
19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience14
Completeness75
Years active:0State licenses:1Digital endpointsOther names

Provider Addresses for Unknown Individual

  • 1200 N STATE HIGHWAY 121

    MT ZION, IL 625491224

    Phone: (217) 864-5531

    Fax: (217) 864-2449

    Type: Mailing

  • 1005 HEALTH CENTER DR STE 201

    MATTOON, IL 619384653

    Phone: (217) 342-3400

    Fax: (217) 258-2216

    Type: Mailing

  • 1215 W MAIN ST

    SHELBYVILLE, IL 625651252

    Phone: (217) 774-4305

    Fax: (217) 774-4306

    Type: Location

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 62549)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.
PAC ID: 6204731144View full group profile
NameSpecialtyState
DR. STEPHEN R GOETTER (M.D.)
-IL
DR. RANJODH SINGH (MD)
General Surgery, Colorectal Surgery (Proctology)IL
DR. RITA MUKERJI (MD)
Cardiovascular Disease (Cardiology), Internal Medicine, Interventional CardiologyMO
KIMBERLY A KISH (APN, CNP)
Nurse PractitionerIL
DAVID W BAUMBERGER (M.D.)
-IL
DR. BETHANY T GIBSON (M.D.)
-IL
DR. BETHANY MORGAN GEBUR (DMSC, MPAS, PA-C)
Physician AssistantIL
TIMOTHY S BAILEY (M.D.)
-IL
TONYA SUE WHITE (NP-C)
-IL
DR. MICHAEL M WALL (M.D.)
Internal MedicineIL

Reviews

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Frequently asked questions

How do I look up Unknown Individual by NPI?
Use NPI 1053315812 when you need to reference Unknown Individual in forms, claims, or directories.
Should I trust care from Unknown Individual if status is inactive?
An inactive NPI does not by itself prove someone stopped practicing — check other sources.
What does Unknown Individual treat or focus on?
Patients typically see Unknown Individual under the specialty Family Medicine Physician. Clinical services aligned with this taxonomy classification.
Where does public data place Unknown Individual?
The snapshot lists Mt Zion, Illinois for Unknown Individual; download NPPES for the complete set.
How can I contact Unknown Individual?
Phone or fax may appear on the official NPI record when supplied — verify before relying on them.

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