Provider Demographics
NPI:1477097871
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:REGIONAL CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLER
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:314-989-2492
Mailing Address - Street 1:1145 CORPORATE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-2907
Mailing Address - Country:US
Mailing Address - Phone:314-989-2492
Mailing Address - Fax:314-344-7281
Practice Address - Street 1:400 N PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3056
Practice Address - Country:US
Practice Address - Phone:618-436-6056
Practice Address - Fax:618-532-9365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-05
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002642207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty