Provider Demographics
NPI:1083066674
Name:IROQUOIS MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:IROQUOIS MEMORIAL HOSPITAL
Other - Org Name:IMH GENERAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GWALTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-432-7966
Mailing Address - Street 1:200 E FAIRMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1644
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 E FAIRMAN AVE
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1644
Practice Address - Country:US
Practice Address - Phone:815-432-7966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty