Provider Demographics
NPI:1083617245
Name:ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS
Entity Type:Organization
Organization Name:ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS
Other - Org Name:SSM HEALTH ST. MARY'S HOSPITAL - CENTRALIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARBISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-436-8000
Mailing Address - Street 1:1195 CORPORATE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-1716
Mailing Address - Country:US
Mailing Address - Phone:314-989-3524
Mailing Address - Fax:314-989-3695
Practice Address - Street 1:400 N PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801
Practice Address - Country:US
Practice Address - Phone:618-436-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002642273R00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL133046300OtherACS OWCP
IL105814OtherHEALTHLINK
IL003578OtherHEALTH ALLIANCE
IL30045800OtherBLACK LUNG
IL35110OtherGROUP HEALTH PLAN
IL0182OtherBLUE CROSS BLUE SHIELD
IL105814OtherHEALTHLINK
IL30045800OtherBLACK LUNG
IL133046300OtherACS OWCP