Healthcare Provider Details

I. General information

NPI: 1669969531
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: 04/17/2018
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD STE 1300
O FALLON IL
62269-1281
US

IV. Provider business mailing address

3051 HOLLIS DR
SPRINGFIELD IL
62704-7450
US

V. Phone/Fax

Practice location:
  • Phone: 618-607-5111
  • Fax: 217-610-8438
Mailing address:
  • Phone: 618-607-5111
  • Fax: 217-610-8438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054.020399
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number054.020399
License Number StateIL

VIII. Authorized Official

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