NPIMap

Organization Active NPI

Iroquois Memorial Hospital and Resident Home

  • Rural Health Clinic/Center
  • Gilman, IL
National Provider Identifier
1366469132
Registry record updated Jan 17, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Practice address
508 E Crescent St
Gilman, IL 60938-1702
Phone
(812) 265-8889
Fax
(815) 265-8332
NPI assigned
Jul 16, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 17, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Timothy Smith
Title
Coo
Phone
(815) 432-7967

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

508 E Crescent St
Gilman, IL 60938-1702

Mailing address

508 E Crescent St
Gilman, IL 60938-1702
Phone (812) 265-8889

Other identifiers 1

IdentifierTypeStateIssuer
0003815088OtherILBCBS OF IL

Other names 1

  • IMH Gilman Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100603000659 IL Part A Provider - Rural Health Clinic 4385551258 Practice locations: Gilman, IL

Rural health clinic certification: CCN 143424

Legal name
IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Doing business as
GILMAN CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 4, 1996
Last certification
Dec 29, 2022
Ownership / control type
2A
Organization structure
CorporationNon-profit
Incorporated
Oct 4, 1921 in IL
Enrollment address
720 E Crescent St
Ste B
Gilman, IL 60938-1518
Related CCNs
140167

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D0976924I M H Gilman Clinic720 E Crescent St - Ste B, Gilman, IL 60938Certificate of waiverAug 15, 2026

National Provider Directory

National Provider Directory
Tax ID family
Iroquois Memorial Hospi15 organizations share this tax ID, including this one

Other organizations with this tax ID 14

Organizations that report the same tax identification number in the National Provider Directory.

View all 14

Locations

34 E Jones St
Milford, IL 60953
Phone (815) 889-4241

Ownership & related parties

All disclosed owners & managing parties 8

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Michelle Fox Individual W-2 Managing Employee Sep 1, 2018
Michael Tilstra Individual Corporate OfficerCeo Jan 17, 2022
Daniel Tincher Individual Corporate DirectorSecretary Jul 1, 2024
Adam Knapp Individual Corporate Director Jul 1, 2024
Sara J Mikuta Individual Corporate DirectorTreasurer Dec 28, 2024
Philip Zumwalt Individual Corporate Director Jul 1, 2024
Rhonda Pence Individual Corporate DirectorBoard Chair Feb 1, 2014
Roger Dittrich Individual Corporate Director Dec 21, 2024

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1484611200000",
    "number": "1366469132",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "508 E CRESCENT ST",
            "city": "GILMAN",
            "state": "IL",
            "postal_code": "609381702",
            "telephone_number": "812-265-8889",
            "fax_number": "815-265-8332"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "508 E CRESCENT ST",
            "city": "GILMAN",
            "state": "IL",
            "postal_code": "609381702",
            "telephone_number": "812-265-8889",
            "fax_number": "815-265-8332"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-16",
        "last_updated": "2017-01-17",
        "status": "A",
        "authorized_official_last_name": "SMITH",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "815-432-7967"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF IL",
            "identifier": "0003815088",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "IMH Gilman Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Gilman, IL

Sources for this page

Verify at the official NPI Registry.