Healthcare Provider Details

I. General information

NPI: 1104849165
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: 07/25/2006
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 N GREEN MOUNT RD SUITE 108
O FALLON IL
62269-1953
US

IV. Provider business mailing address

3051 HOLLIS DR
SPRINGFIELD IL
62704-7450
US

V. Phone/Fax

Practice location:
  • Phone: 618-624-5510
  • Fax: 618-624-5525
Mailing address:
  • Phone: 618-624-5510
  • Fax: 618-624-5525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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