Healthcare Provider Details

I. General information

NPI: 1790789451
Provider Name (Legal Business Name): ST. MARY'S HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NEW YORK DR STE 2
VANDALIA IL
62471-1044
US

IV. Provider business mailing address

PO BOX 503861
SAINT LOUIS MO
63150-0001
US

V. Phone/Fax

Practice location:
  • Phone: 618-283-0600
  • Fax:
Mailing address:
  • Phone: 618-436-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number0002642
License Number StateIL

VIII. Authorized Official

Name: MR. BRUCE MERRELL
Title or Position: PRESIDENT
Credential:
Phone: 618-436-6205