Healthcare Provider Details

I. General information

NPI: 1477097871
Provider Name (Legal Business Name): ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PLEASANT AVE
CENTRALIA IL
62801-3056
US

IV. Provider business mailing address

1145 CORPORATE LAKE DR
SAINT LOUIS MO
63132-2907
US

V. Phone/Fax

Practice location:
  • Phone: 618-436-6056
  • Fax: 618-532-9365
Mailing address:
  • Phone: 314-989-2492
  • Fax: 314-344-7281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number0002642
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0002642
License Number StateIL

VIII. Authorized Official

Name: MR. TIM BULLER
Title or Position: REGIONAL CFO
Credential: CFO
Phone: 314-989-2492