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General NPI Number Information
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NPI Number | 1598946543
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Entity Type | Organization
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Legal Business Name | ST. MARY'S HOSPITAL
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Dates
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Enumeration Date | 11/19/2007
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Last Update Date | 05/13/2009
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Provider Practice Location Address
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Address Line | 104 E BRIDGE ST
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City | STREATOR
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State | IL
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Zip | 61364-2967
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Country | US
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Telephone | 815-672-4015
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Fax |
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Provider Business Mailing Address
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Address Line | 104 E BRIDGE ST
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City | STREATOR
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State | IL
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Zip | 61364-2967
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Country | US
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Telephone | 815-672-4015
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Fax |
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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 | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 036078501
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License Number State | IL
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