Basic Information
| Provider Information | |||||||||
| NPI: | 1306800602 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. ANTHONY'S MEMORIAL HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD O | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. ANTHONY'S MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 503 N MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624012006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173471333 | ||||||||
| FaxNumber: | 2173471565 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 N MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624012099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173471333 | ||||||||
| FaxNumber: | 2173471565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STORM | ||||||||
| AuthorizedOfficialFirstName: | DAVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2173422121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 1630809 | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0060089 | 01 | AETNA | OTHER | 379091 | 01 | BLACK LUNG | OTHER | 2515006 | 01 | IL | BLUE SHIELD | OTHER | 116692 | 01 | HEALTH LINK | OTHER | 619698624 | 01 | FIRST HEALTH | OTHER | 003650 | 01 | HEALTH ALLIANCE | OTHER | 169 | 01 | IL | BLUE CROSS | OTHER |