Healthcare Provider Details

I. General information

NPI: 1255391611
Provider Name (Legal Business Name): ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PLEASANT AVE
CENTRALIA IL
62801
US

IV. Provider business mailing address

1195 CORPORATE LAKE DR
SAINT LOUIS MO
63132-1716
US

V. Phone/Fax

Practice location:
  • Phone: 618-436-8000
  • Fax:
Mailing address:
  • Phone: 314-989-3524
  • Fax: 314-989-3695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number0002642
License Number StateIL

VIII. Authorized Official

Name: MR. DAMON R HARBISON
Title or Position: PRESIDENT
Credential:
Phone: 618-436-8000