Basic Information
| Provider Information | |||||||||
| NPI: | 1982668851 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST MARY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OSF SAINT MARY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 SW ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616021320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096552850 | ||||||||
| FaxNumber: | 3096554878 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 N SEMINARY ST | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614011251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093443161 | ||||||||
| FaxNumber: | 3093449498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 02/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCGREW | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, OSF HEALTHCARE SYSTEM | ||||||||
| AuthorizedOfficialTelephone: | 3096552850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OSF HEALTHCARE SYSTEM | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1419785 | 01 | IL | UNITED MINE WORKERS | OTHER | 4815066 | 01 | IL | BLUE SHIELD | OTHER | CD1847 | 01 | IL | MEDICARE RR | OTHER |