1164673307 NPI number — ST MARYS HOSPITAL

Table of content: (NPI 1164673307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164673307 NPI number — ST MARYS HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST MARYS 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:
ST MARYS ORTHOPEDICS
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:
1164673307
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 W 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STREATOR
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61364-2899
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-673-3223
Provider Business Mailing Address Fax Number:
815-673-3305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 W 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STREATOR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61364-2899
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-673-3223
Provider Business Practice Location Address Fax Number:
815-673-3305
Provider Enumeration Date:
10/07/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
815-673-4514

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  036070970 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1659330090 . This is a "MD NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9924600 . This is a "CIGNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036070970 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1164673307 . This is a "BLUESHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".