Provider Demographics
NPI:1578580346
Name:IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Entity Type:Organization
Organization Name:IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Other - Org Name:IMH MILFORD 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:815-432-7967
Mailing Address - Street 1:34 E JONES ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:IL
Mailing Address - Zip Code:60953-1046
Mailing Address - Country:US
Mailing Address - Phone:815-889-4241
Mailing Address - Fax:815-889-4244
Practice Address - Street 1:34 E JONES ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:IL
Practice Address - Zip Code:60953-1046
Practice Address - Country:US
Practice Address - Phone:815-889-4241
Practice Address - Fax:815-889-4244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
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
IL0003815085OtherBC/BS OF IL
IL=========005Medicaid