Provider Demographics
NPI:1285718478
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:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHLMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-432-7735
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:2006-10-24
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001107275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14U167Medicare Oscar/Certification