1083617245 NPI number — ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Table of content: (NPI 1083617245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083617245 NPI number — ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS
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:
SSM HEALTH ST. MARY'S HOSPITAL - CENTRALIA
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:
1083617245
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1195 CORPORATE LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63132-1716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-989-3524
Provider Business Mailing Address Fax Number:
314-989-3695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N PLEASANT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-436-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HARBISON
Authorized Official First Name:
DAMON
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-436-8000

Provider Taxonomy Codes

  • Taxonomy code: 273R00000X , with the licence number:  0002642 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 0002642 , 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: 133046300 . This is a "ACS OWCP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 105814 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 003578 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 30045800 . This is a "BLACK LUNG" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 35110 . This is a "GROUP HEALTH PLAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0182 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 119249000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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