Basic Information
| Provider Information | |||||||||
| NPI: | 1205469350 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOSEPH'S HOSPITAL, BREESE, OF THE HOSPITAL SISTERS OF THE THIRD OR | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HSHS ST. JOSEPH'S HOSPITAL | ||||||||
| 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: | |||||||||
| Practice Location | |||||||||
| Address1: | 9515 HOLY CROSS LN | ||||||||
| Address2: | |||||||||
| City: | BREESE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622303618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185264511 | ||||||||
| FaxNumber: | 6182224703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2020 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLAY | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 6185265300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST JOSEPHS HOSPITAL BREESE OF THE HOSPITAL SISTERS OF THE THIRD ORDER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.