Provider Demographics
NPI:1457319154
Name:ST JOSEPHS HOSPITAL BREESE OF THE HOSPITAL SISTERS OF THE THIRD ORDER
Entity Type:Organization
Organization Name:ST JOSEPHS HOSPITAL BREESE OF THE HOSPITAL SISTERS OF THE THIRD ORDER
Other - Org Name:ST. JOSEPH'S HOSPITAL
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:DUANE
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:618-526-4511
Mailing Address - Fax:618-526-2291
Practice Address - Street 1:9515 HOLY CROSS LN
Practice Address - Street 2:BOX 99
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-3618
Practice Address - Country:US
Practice Address - Phone:618-526-4511
Practice Address - Fax:618-526-2291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002527282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0660303OtherCIGNA
IL0181OtherBLUE CROSS
IL133379500OtherFEDERAL WORKCOMP
IL35042OtherGRP HLTH PLAN PROFEE ANES
IL730007OtherCIGNA HLTHLNK PROFEE
IL27450OtherGROUP HEALTH PLAN
IL01419513OtherBLUE CROSS PROFEE
IL130531OtherHEALTHLINK
IL730003OtherCIGNA HEALTHLINK
IL5007008OtherUNITED HEALTHCARE
IL0660303OtherCIGNA
IL5007008OtherUNITED HEALTHCARE
IL=========OtherCOMMERCIAL
IL730007OtherCIGNA HLTHLNK PROFEE
IL14-0145Medicare ID - Type UnspecifiedMEDICARE
IL01419513OtherBLUE CROSS PROFEE
IL5007008OtherUNITED HEALTHCARE