=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740088210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST JOHNS HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST F
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2025
-----------------------------------------------------
Last Update Date | 03/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 E CARPENTER ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62702-5324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-544-6464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3051 HOLLIS DR
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62704-7450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-641-5492
-----------------------------------------------------
Fax | 618-607-5997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT OF REVENUE CYCLE
-----------------------------------------------------
Name | MARK DUANE EVARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-492-9651
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0404X
-----------------------------------------------------
Taxonomy Name | Cardiac Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------