MEDICARE: ST JOSEPHS HOSPITAL BREESE OF THE HOSPITAL SISTERS OF THE THIRD ORDE

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	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1780047944
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST JOSEPHS HOSPITAL BREESE OF THE HOSPITAL SISTERS OF THE THIRD ORDE

Provider Business Mailing Address
First Line	:	3051 HOLLIS DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-7450
Country	:	US
Telephone Number	:	618-594-3613
Fax Number	:	188-885-9434

Provider Business Practice Location Address
First Line	:	14509 STATE ROUTE 127
Second Line	:
City	:	CARLYLE
State	:	IL
Zip	:	62231-6485
Country	:	US
Telephone Number	:	618-594-3613
Fax Number	:

Authorized Official
Title or Position	:	VP OF REVENUE CYCLE
Name	:	MARK DUANE EVARD
Credential	:
Telephone Number	:	217-492-9651

Provider Enumeration Date	:	04/04/2016
Last Update Date	:	10/31/2024

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