Basic Information
| Provider Information | |||||||||
| NPI: | 1407067978 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT ELIZABETH'S HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 772 GLEN MOR | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622213482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182771951 | ||||||||
| FaxNumber: | 6182773738 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622201915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BOUSE | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | RUDOLPH | ||||||||
| AuthorizedOfficialTitleorPosition: | STAFF OCCUPATIONAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 6182342120 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | B.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | IL | Y | Hospitals | General Acute Care Hospital |
No ID Information.