Provider Demographics
NPI:1841295763
Name:IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Entity type:Organization
Organization Name:IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TILSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-432-7777
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:815-432-0185
Mailing Address - Fax:815-432-6199
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:815-432-0185
Practice Address - Fax:815-432-6199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2002400251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL50344OtherBCBS PROVIDER #
IL=========010Medicaid
IL50344OtherBCBS PROVIDER #