{
"Npi": {
"NPI": "1144729716",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "ST. ELIZABETH'S HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER",
"ParentOrgTIN": null,
"OrgName": "ST ELIZABETHS HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "3051 HOLLIS DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SPRINGFIELD",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "62704-7450",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "618-235-0651",
"MailingAddressFaxNumber": "618-223-5780",
"FirstLinePracticeLocationAddress": "180 SOUTH THIRD STREET SUITE 101",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "BELLEVILLE",
"PracticeLocationAddressStateName": "IL",
"PracticeLocationAddressPostalCode": "62220",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": null,
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "02/08/2018",
"LastUpdateDate": "10/31/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "EVARD",
"AuthorizedOfficialFirstName": "MARK",
"AuthorizedOfficialMiddleName": "D",
"AuthorizedOfficialTitle": "VP OF REVENUE CYCLE",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "217-492-9651",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "261QR0206X",
"TaxonomyName": "Mammography Clinic/Center",
"LicenseNumber": "9003609",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QR0200X",
"TaxonomyName": "Radiology Clinic/Center",
"LicenseNumber": "9003609",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}