Basic Information
| Provider Information | |||||||||
| NPI: | 1043831134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST ANTHONY'S MEMORIAL HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD OR | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HSHS ST. ANTHONY'S IMAGING CENTER MATTOON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 S 3RD ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622201952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342120 | ||||||||
| FaxNumber: | 6182224703 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 COLES CENTRE PKWY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183422121 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2020 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NOSACKA | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6186415468 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST ANTHONY'S MEMORIAL HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD OR | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.