Provider Demographics
NPI:1629003470
Name:IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Entity type:Organization
Organization Name:IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR MEDICAL STAFF & IT SVCS
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-432-7775
Mailing Address - Street 1:200 E FAIRMAN AVE
Mailing Address - Street 2:
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 - Street 2:
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
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
275N00000X, 3336C0002X, 3336C0003X, 3336L0003X, 282NC0060X
IL0001107282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
No282NR1301XHospitalsGeneral Acute Care HospitalRural
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL150OtherBLUE CROSS
IN200262610AMedicaid
IL004126OtherHEALTH ALLIANCE
IN100037080AMedicaid
ILN198101Medicaid
IL88916Medicaid
IL003815082OtherBLUE SHIELD
IL=========001Medicaid
ILN198101Medicaid
IL=========401Medicaid
IN200262610AMedicaid
IL=========401Medicaid
IL140167Medicare Oscar/Certification
IL150OtherBLUE CROSS
ILN198101Medicaid