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1770687196

NPI Code Detail

MEDICARE: ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS

MEDICARE: ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0011X	Interventional Cardiology Physician	0002642	IL
2	208100000X	Physical Medicine & Rehabilitation Physician	0002642	IL
3	2084N0400X	Neurology Physician	0002642	IL
4	2085R0001X	Radiation Oncology Physician	0002642	IL
5	2085R0202X	Diagnostic Radiology Physician	0002642	IL
6	227800000X	Certified Respiratory Therapist	0002642	IL
7	227900000X	Registered Respiratory Therapist	0002642	IL
8	207P00000X	Emergency Medicine Physician	0002642	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	35110	OTHER	IL	GROUP HEALTH PLAN
2	6110182	OTHER	IL	BLUE CROSS BLUE SHIELD
3	247625	OTHER	IL	HEALTHLINK NUMBER

General Provider Information

NPI Number	:	1770687196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Provider Business Mailing Address
First Line	:	1145 CORPORATE LAKE DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63132-2907
Country	:	US
Telephone Number	:	314-989-2492
Fax Number	:	314-344-7281

Provider Business Practice Location Address
First Line	:	400 N PLEASANT AVE
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3056
Country	:	US
Telephone Number	:	618-436-8000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DAMON R HARBISON
Credential	:	CFO
Telephone Number	:	618-436-6205

Provider Enumeration Date	:	09/08/2006
Last Update Date	:	11/27/2023

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Directions to “ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS ” Practice Location

Language	Start Address	Practice Location

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