1467470906 NPI number — IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME

Table of content: (NPI 1467470906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467470906 NPI number — IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
IMH KENTLAND CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467470906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 N 7TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENTLAND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47951-1379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-474-5464
Provider Business Mailing Address Fax Number:
219-474-3603

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 N 7TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENTLAND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47951-1379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-474-5464
Provider Business Practice Location Address Fax Number:
219-474-3603
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
81584327967

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200133940A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0003815082 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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