Provider Demographics
NPI:1285630624
Name:ST. MARY'S HOSPITAL
Entity Type:Organization
Organization Name:ST. MARY'S HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-436-6205
Mailing Address - Street 1:PO BOX 503861
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-0001
Mailing Address - Country:US
Mailing Address - Phone:618-249-6203
Mailing Address - Fax:
Practice Address - Street 1:205 HURON
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:IL
Practice Address - Zip Code:62848
Practice Address - Country:US
Practice Address - Phone:618-249-6203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002642261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL128375OtherHEALTHLINK
IL9515007OtherBLUE CROSS BLUE SHIELD
IL=========004Medicaid
IL128375OtherHEALTHLINK
IL9515007OtherBLUE CROSS BLUE SHIELD