Basic Information
| Provider Information | |||||||||
| NPI: | 1194736728 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. ELIZABETH'S HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. ELIZABETH'S BHS PROFESSIONAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622201915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342120 | ||||||||
| FaxNumber: | 6182224761 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622201915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342120 | ||||||||
| FaxNumber: | 6182224761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NOSACKA | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6186415468 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0002345 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LP0808X | 041.334033 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 2084A0401X | 0002345 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
No ID Information.