Basic Information
| Provider Information | |||||||||
| NPI: | 1629003470 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 200 E FAIRMAN AVE | ||||||||
| Address2: | |||||||||
| City: | WATSEKA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609701644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154325841 | ||||||||
| FaxNumber: | 8154327821 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E FAIRMAN AVE | ||||||||
| Address2: | |||||||||
| City: | WATSEKA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609701644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154325841 | ||||||||
| FaxNumber: | 8154327821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR MEDICAL STAFF & IT SVCS | ||||||||
| AuthorizedOfficialTelephone: | 8154327775 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 282NR1301X | 0001107 | IL | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 150 | 01 | IL | BLUE CROSS | OTHER | 88916 | 05 | IL | MEDICAID | N198101 | 05 | IL | MEDICAID | 200262610A | 05 | IN | MEDICAID | 100037080A | 05 | IN | MEDICAID | 003815082 | 01 | IL | BLUE SHIELD | OTHER | 004126 | 01 | IL | HEALTH ALLIANCE | OTHER |