Provider Demographics
NPI:1457358285
Name:FORD-IROQUOIS PUBLIC HEALTH DEPT
Entity Type:Organization
Organization Name:FORD-IROQUOIS PUBLIC HEALTH DEPT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL AID COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-432-2483
Mailing Address - Street 1:114 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1302
Mailing Address - Country:US
Mailing Address - Phone:815-432-2483
Mailing Address - Fax:815-432-2198
Practice Address - Street 1:114 N 3RD ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1302
Practice Address - Country:US
Practice Address - Phone:815-432-2483
Practice Address - Fax:815-432-2198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1001528251B00000X, 251E00000X, 251J00000X, 251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL690333015002Medicaid
IL9622OtherBLUE CROSS BLUE SHIELD
IL147110Medicare ID - Type UnspecifiedPROVIDER NUMBER