MEDICARE: ST MARY MEDICAL CENTER

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	367500000X	Certified Registered Nurse Anesthetist

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CD1847	OTHER	IL	MEDICARE RR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4815066	OTHER	IL	BLUE SHIELD
2	1419785	OTHER	IL	UNITED MINE WORKERS

General Provider Information

NPI Number	:	1982668851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST MARY MEDICAL CENTER

Provider Business Mailing Address
First Line	:	124 SW ADAMS ST
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61602-1320
Country	:	US
Telephone Number	:	309-655-2850
Fax Number	:	309-655-4878

Provider Business Practice Location Address
First Line	:	3333 N SEMINARY ST
Second Line	:
City	:	GALESBURG
State	:	IL
Zip	:	61401-1251
Country	:	US
Telephone Number	:	309-344-3161
Fax Number	:	309-344-9498

Authorized Official
Title or Position	:	CEO
Name	:	ROBERT C SEHRING
Credential	:
Telephone Number	:	309-655-2850

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	03/18/2024

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Directions to “ST MARY MEDICAL CENTER ” Practice Location

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