MEDICARE: ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	273R00000X	Psychiatric Hospital Unit	0002642	IL
2	282N00000X	General Acute Care Hospital	0002642	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	133046300	OTHER	IL	ACS OWCP
2	105814	OTHER	IL	HEALTHLINK
3	003578	OTHER	IL	HEALTH ALLIANCE
4	30045800	OTHER	IL	BLACK LUNG
5	35110	OTHER	IL	GROUP HEALTH PLAN
6	0182	OTHER	IL	BLUE CROSS BLUE SHIELD
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083617245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Provider Business Mailing Address
First Line	:	1195 CORPORATE LAKE DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63132-1716
Country	:	US
Telephone Number	:	314-989-3524
Fax Number	:	314-989-3695

Provider Business Practice Location Address
First Line	:	400 N PLEASANT AVE
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801
Country	:	US
Telephone Number	:	618-436-8000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DAMON R HARBISON
Credential	:
Telephone Number	:	618-436-8000

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	11/27/2023

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