Healthcare Provider Details

I. General information

NPI: 1205469350
Provider Name (Legal Business Name): ST JOSEPHS HOSPITAL BREESE OF THE HOSPITAL SISTERS OF THE THIRD ORDE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9515 HOLY CROSS LN
BREESE IL
62230-3618
US

IV. Provider business mailing address

3051 HOLLIS DR
SPRINGFIELD IL
62704-7450
US

V. Phone/Fax

Practice location:
  • Phone: 618-526-4511
  • Fax: 618-222-4703
Mailing address:
  • Phone: 618-234-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

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