1780604371 NPI number — IROQUOIS MEMORIAL HOSPITAL

Table of content: ROBERT NORMAN CHARTRAND PTA (NPI 1073094074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780604371 NPI number — IROQUOIS MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IROQUOIS MEMORIAL HOSPITAL
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 SHELDON 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:
1780604371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 E GROVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELDON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-429-3314
Provider Business Mailing Address Fax Number:
815-429-3490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 E GROVE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELDON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-429-3314
Provider Business Practice Location Address Fax Number:
815-429-3490
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEURCK
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
O
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
815-432-7736

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: 0003832005 . This is a "BLUS CROSS BLUE SHIELD IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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