Basic Information
| Provider Information | |||||||||
| NPI: | 1326070921 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. ELIZABETH HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BELLEVILLE FAMILY PRACTICE RESIDENCY PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 S 3RD ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622201952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342120 | ||||||||
| FaxNumber: | 6182224703 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 S 3RD ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622201952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342120 | ||||||||
| FaxNumber: | 6182224703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | NOSACKA | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6186415468 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.