Provider Demographics
NPI:1003091570
Name:ST. ELIZABETH HOSPITAL
Entity Type:Organization
Organization Name:ST. ELIZABETH HOSPITAL
Other - Org Name:ELDERMED SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:EVARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-492-9651
Mailing Address - Street 1:3051 HOLLIS DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7450
Mailing Address - Country:US
Mailing Address - Phone:618-234-2120
Mailing Address - Fax:618-222-4703
Practice Address - Street 1:1512 N GREEN MOUNT RD
Practice Address - Street 2:SUITE 200
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1953
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:618-222-4703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115149OtherINTERNAL MEDICINE