Provider Demographics
NPI:1467470906
Name:IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Entity Type:Organization
Organization Name:IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Other - Org Name:IMH KENTLAND CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:8158-432-7967
Mailing Address - Street 1:303 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:KENTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47951-1379
Mailing Address - Country:US
Mailing Address - Phone:219-474-5464
Mailing Address - Fax:219-474-3603
Practice Address - Street 1:303 N 7TH ST
Practice Address - Street 2:
Practice Address - City:KENTLAND
Practice Address - State:IN
Practice Address - Zip Code:47951-1379
Practice Address - Country:US
Practice Address - Phone:219-474-5464
Practice Address - Fax:219-474-3603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200133940AMedicaid
IL0003815082OtherBLUE CROSS BLUE SHIELD
IL0003815082OtherBLUE CROSS BLUE SHIELD