Basic Information
Provider Information | |||||||||
NPI: | 1629057302 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. ELIZABETH'S HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HSHS ST. ELIZABETH'S HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 211 S 3RD ST | ||||||||
Address2: |   | ||||||||
City: | BELLEVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622201915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182342120 | ||||||||
FaxNumber: | 6182224628 | ||||||||
Practice Location | |||||||||
Address1: | 1 SAINT ELIZABETH BLVD | ||||||||
Address2: |   | ||||||||
City: | O FALLON | ||||||||
State: | IL | ||||||||
PostalCode: | 622691099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182342120 | ||||||||
FaxNumber: | 6186415486 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NOSACKA | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6186415468 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   | IL | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 0064066 | 01 |   | BLUE CHOICE | OTHER | 010779908 | 05 | MO |   | MEDICAID | 6701313 | 01 |   | UHC METRAHEALTH | OTHER | 0914 | 01 | MO | BLUE CROSS | OTHER | 4489 | 01 |   | GHP | OTHER | 107847 | 01 |   | HEALTHLINK | OTHER |