1710105192 NPI number — ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Table of content: (NPI 1710105192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710105192 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:
1710105192
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:
PO BOX 503861
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:
63150-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-436-8000
Provider Business Mailing Address Fax Number:

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:
04/23/2007

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:
618-436-6205

Provider Taxonomy Codes

  • Taxonomy code: 261QR0401X , 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: 6123830 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com