Basic Information
| Provider Information | |||||||||
| NPI: | 1477097871 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SSM HEALTH ST. MARY'S HOSPITAL - CENTRALIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1145 CORPORATE LAKE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631322907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149892492 | ||||||||
| FaxNumber: | 3143447281 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N PLEASANT AVE | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628013056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184366056 | ||||||||
| FaxNumber: | 6185329365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2016 | ||||||||
| LastUpdateDate: | 03/26/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BULLER | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL CFO | ||||||||
| AuthorizedOfficialTelephone: | 3149892492 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 0002642 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | 0002642 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.