Basic Information
| Provider Information | |||||||||
| NPI: | 1770687196 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SSM HEALTH ST. MARY'S HOSPITAL - CENTRALIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 6184368000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | HARBISON | ||||||||
| AuthorizedOfficialFirstName: | DAMON | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6184366205 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CFO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 0002642 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 208100000X | 0002642 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2084N0400X | 0002642 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2085R0001X | 0002642 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0202X | 0002642 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 227800000X | 0002642 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Certified | 227900000X | 0002642 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | 207P00000X | 0002642 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 35110 | 01 | IL | GROUP HEALTH PLAN | OTHER | 6110182 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 247625 | 01 | IL | HEALTHLINK NUMBER | OTHER |