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General NPI Number Information
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NPI Number | 1164673307
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Entity Type | Organization
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Legal Business Name | ST MARYS HOSPITAL
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Dates
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Enumeration Date | 10/07/2008
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Last Update Date | 04/22/2009
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Provider Practice Location Address
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Address Line | 104 W 6TH ST
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City | STREATOR
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State | IL
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Zip | 61364-2899
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Country | US
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Telephone | 815-673-3223
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Fax | 815-673-3305
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Provider Business Mailing Address
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Address Line | 104 W 6TH ST
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City | STREATOR
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State | IL
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Zip | 61364-2899
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Country | US
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Telephone | 815-673-3223
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Fax | 815-673-3305
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Authorized Official
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Title or Position | CFO
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Name | KAREN S CLARK
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Credential |
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Telephone | 815-673-4514
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 036070970
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License Number State | IL
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