Basic Information
| Provider Information | |||||||||
| NPI: | 1083617245 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SSM HEALTH ST. MARY'S HOSPITAL - CENTRALIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1195 CORPORATE LAKE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631321716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149893524 | ||||||||
| FaxNumber: | 3149893695 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N PLEASANT AVE | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184368000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARBISON | ||||||||
| AuthorizedOfficialFirstName: | DAMON | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6184368000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 0002642 | IL | N | Hospital Units | Psychiatric Unit | 282N00000X | 0002642 | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 133046300 | 01 | IL | ACS OWCP | OTHER | 105814 | 01 | IL | HEALTHLINK | OTHER | 003578 | 01 | IL | HEALTH ALLIANCE | OTHER | 30045800 | 01 | IL | BLACK LUNG | OTHER | 35110 | 01 | IL | GROUP HEALTH PLAN | OTHER | 0182 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |