Healthcare Provider Details

I. General information

NPI: 1144729716
Provider Name (Legal Business Name): ST ELIZABETHS HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 SOUTH THIRD STREET SUITE 101
BELLEVILLE IL
62220
US

IV. Provider business mailing address

3051 HOLLIS DR
SPRINGFIELD IL
62704-7450
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 618-235-0651
  • Fax: 618-223-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number9003609
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number9003609
License Number StateIL

VIII. Authorized Official

Name: MARK D EVARD
Title or Position: VP OF REVENUE CYCLE
Credential:
Phone: 217-492-9651