Basic Information
| Provider Information | |||||||||
| NPI: | 1457319154 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST JOSEPHS HOSPITAL BREESE OF THE HOSPITAL SISTERS OF THE THIRD ORDER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. JOSEPH'S HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9515 HOLY CROSS LN | ||||||||
| Address2: | BOX 99 | ||||||||
| City: | BREESE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622303618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185264511 | ||||||||
| FaxNumber: | 6185262291 | ||||||||
| Practice Location | |||||||||
| Address1: | 9515 HOLY CROSS LN | ||||||||
| Address2: | BOX 99 | ||||||||
| City: | BREESE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622303618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185264511 | ||||||||
| FaxNumber: | 6185262291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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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 | 282N00000X | 0002527 | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 01419513 | 01 | IL | BLUE CROSS PROFEE | OTHER | 0181 | 01 | IL | BLUE CROSS | OTHER | 130531 | 01 | IL | HEALTHLINK | OTHER | 5007008 | 01 | IL | UNITED HEALTHCARE | OTHER | 133379500 | 01 | IL | FEDERAL WORKCOMP | OTHER | 27450 | 01 | IL | GROUP HEALTH PLAN | OTHER | 730003 | 01 | IL | CIGNA HEALTHLINK | OTHER | 0660303 | 01 | IL | CIGNA | OTHER | 35042 | 01 | IL | GRP HLTH PLAN PROFEE ANES | OTHER | 730007 | 01 | IL | CIGNA HLTHLNK PROFEE | OTHER |