Provider Demographics
NPI:1790889194
Name:IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Entity Type:Organization
Organization Name:IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Other - Org Name:IMH MULTI-SPECIALTY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHLMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-432-7736
Mailing Address - Street 1:200 LAIRD LN
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-7568
Mailing Address - Country:US
Mailing Address - Phone:815-432-5411
Mailing Address - Fax:815-432-3955
Practice Address - Street 1:200 LAIRD LN
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-7568
Practice Address - Country:US
Practice Address - Phone:815-432-5411
Practice Address - Fax:815-432-3955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214521Medicare PIN