Healthcare Provider Details

I. General information

NPI: 1790889194
Provider Name (Legal Business Name): IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 LAIRD LN
WATSEKA IL
60970-7568
US

IV. Provider business mailing address

200 LAIRD LN
WATSEKA IL
60970-7568
US

V. Phone/Fax

Practice location:
  • Phone: 815-432-5411
  • Fax: 815-432-3955
Mailing address:
  • Phone: 815-432-5411
  • Fax: 815-432-3955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHUCK BOHLMANN
Title or Position: PRESIDENT/CEO
Credential:
Phone: 815-432-7736