NPIMap

Organization Active NPI

Iroquois Memorial Hospital and Resident Home

Doing business as IMH Multi-Specialty Physicians Clinic

  • Rural Health Clinic/Center
  • Watseka, IL
National Provider Identifier
1447610472
Registry record updated Mar 3, 2016
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
Doing business as
IMH Multi-Specialty Physicians Clinic
Practice address
200 Laird LN
Watseka, IL 60970-7568
Phone
(815) 432-5411
Fax
(815) 432-3955
NPI assigned
Mar 3, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 3, 2016

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

Authorized official

Name
Chuck Bohlmann
Title
Ceo
Phone
(815) 435-7735

Specialties & licenses 1

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

Addresses

Primary practice location

200 Laird LN
Watseka, IL 60970-7568

Mailing address

200 Laird LN
Watseka, IL 60970-7568
Phone (815) 432-5411

Other names 1

  • IMH Multi-Specialty Physicians Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150513002309 IL Part A Provider - Rural Health Clinic 4385551258 1 other NPI on this enrollment
Practice locations: Watseka, IL

Rural health clinic certification: CCN 148551

Legal name
IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Doing business as
IMH MULTI-SPECIALTY PHYSICIANS CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 5, 2016
Last certification
Sep 20, 2022
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Oct 4, 1921 in IL
Enrollment address
200 E Fairman Ave
Watseka, IL 60970-1644
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).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

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

Ownership & related parties

All disclosed owners & managing parties 7

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 Director Feb 17, 2022
Daniel Tincher Individual Corporate OfficerBoard Secretary Mar 9, 2010
Philip Zumwalt Individual Corporate Officer Oct 3, 2006
Rhonda Pence Individual Corporate Officer Feb 1, 2014
Doug Geiger Individual Corporate Officer Feb 1, 2014
Roger Dittrich Individual Corporate OfficerBoard Chairman Sep 28, 2010

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": "1456963200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1456963200000",
    "number": "1447610472",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 LAIRD LN",
            "city": "WATSEKA",
            "state": "IL",
            "postal_code": "609707568",
            "telephone_number": "815-432-5411",
            "fax_number": "815-432-3955"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 LAIRD LN",
            "city": "WATSEKA",
            "state": "IL",
            "postal_code": "609707568",
            "telephone_number": "815-432-5411",
            "fax_number": "815-432-3955"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-03-03",
        "last_updated": "2016-03-03",
        "status": "A",
        "authorized_official_last_name": "BOHLMANN",
        "authorized_official_first_name": "CHUCK",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "815-435-7735"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "IMH Multi-Specialty Physicians Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Watseka, IL

Sources for this page

Verify at the official NPI Registry.