IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME

Provider Demographics

• NPI: 1629003470
• Name: IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
• Entity Type: Organization
• Organization Name: IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
• Authorized Official - Title/Position: DIRECTOR MEDICAL STAFF & IT SVCS
• Authorized Official - Prefix: MRS
• Authorized Official - First Name: MICHELLE
• Authorized Official - Last Name: FOX
• Authorized Official - Phone: 815-432-7775
• Mailing Address - Street 1: 200 E FAIRMAN AVE
• Mailing Address - City: WATSEKA
• Mailing Address - State: IL
• Mailing Address - Zip Code: 60970-1644
• Mailing Address - Country: US
• Mailing Address - Phone: 815-432-5841
• Mailing Address - Fax: 815-432-7821
• Practice Address - Street 1: 200 E FAIRMAN AVE
• Practice Address - City: WATSEKA
• Practice Address - State: IL
• Practice Address - Zip Code: 60970-1644
• Practice Address - Country: US
• Practice Address - Phone: 815-432-5841
• Practice Address - Fax: 815-432-7821
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-07-11
• Last Update Date: 2023-08-10

Provider Licenses

State	License ID	Taxonomies
		282NC0060X, 3336C0002X, 3336C0003X, 3336L0003X
IL	0001107	282NR1301X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	282NC0060X	Hospitals	General Acute Care Hospital	Critical Access
No	282NR1301X	Hospitals	General Acute Care Hospital	Rural
No	3336C0002X	Suppliers	Pharmacy	Clinic Pharmacy
No	3336C0003X	Suppliers	Pharmacy	Community/Retail Pharmacy
No	3336L0003X	Suppliers	Pharmacy	Long Term Care Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IL	004126	Other	HEALTH ALLIANCE
IN	100037080A	Medicaid
IL	150	Other	BLUE CROSS
IN	200262610A	Medicaid
IL	88916	Medicaid
IL	N198101	Medicaid
IL	003815082	Other	BLUE SHIELD
IL	=========001	Medicaid
IL	N198101	Medicaid
IL	=========401	Medicaid
IN	200262610A	Medicaid
IL	=========401	Medicaid
IL	140167	Medicare Oscar/Certification
IL	150	Other	BLUE CROSS
IL	N198101	Medicaid