Provider Demographics
NPI:1780604371
Name:IROQUOIS MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:IROQUOIS MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:O
Authorized Official - Last Name:LEURCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-432-7736
Mailing Address - Street 1:160 E GROVE
Mailing Address - Street 2:
Mailing Address - City:SHELDON
Mailing Address - State:IL
Mailing Address - Zip Code:60966
Mailing Address - Country:US
Mailing Address - Phone:815-429-3314
Mailing Address - Fax:815-429-3490
Practice Address - Street 1:160 E GROVE ST
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:IL
Practice Address - Zip Code:60966
Practice Address - Country:US
Practice Address - Phone:815-429-3314
Practice Address - Fax:815-429-3490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0003832005OtherBLUS CROSS BLUE SHIELD IL
IL0003832005OtherBLUS CROSS BLUE SHIELD IL
IL206677Medicare ID - Type UnspecifiedPART B WPS
IL143468Medicare Oscar/Certification