Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 11/27/2023
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: 618-436-8000
  • Fax:
Mailing address:
  • Phone: 314-989-2492
  • Fax: 314-344-7281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0002642
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number0002642
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0002642
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0002642
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number0002642
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0002642
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number0002642
License Number StateIL
# 8
Primary TaxonomyN
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number0002642
License Number StateIL

VIII. Authorized Official

Name: MR. DAMON R HARBISON
Title or Position: PRESIDENT
Credential: CFO
Phone: 618-436-6205