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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1952496176
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	:	618-523-4216
Fax Number	:	618-523-7049

Provider Business Practice Location Address
First Line	:	205 MUNSTER STREET
Second Line	:
City	:	GERMANTOWN
State	:	IL
Zip	:	62245
Country	:	US
Telephone Number	:	618-523-4216
Fax Number	:	618-523-7049

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

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	10/31/2024

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