Provider Demographics
NPI:1023017423
Name:HEARTLAND MEMORIAL HOSPITAL, LLC
Entity Type:Organization
Organization Name:HEARTLAND MEMORIAL HOSPITAL, LLC
Other - Org Name:ILLIANA SURGERY AND MEDICAL CENTER, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:YESSENOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-922-4200
Mailing Address - Street 1:701 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-4037
Mailing Address - Country:US
Mailing Address - Phone:219-922-4200
Mailing Address - Fax:
Practice Address - Street 1:315 W 89TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6254
Practice Address - Country:US
Practice Address - Phone:219-757-5275
Practice Address - Fax:219-757-5290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN150147Medicare ID - Type Unspecified