Provider Demographics
NPI:1558556878
Name:ST. ELIZABETH'S HOSPITAL
Entity Type:Organization
Organization Name:ST. ELIZABETH'S HOSPITAL
Other - Org Name:NEW DIMENSIONS RECONSTRUCTIVE AND COSMETIC SURGERY
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:618-235-8500
Mailing Address - Fax:618-222-4618
Practice Address - Street 1:2900 FRANK SCOTT PKWY W
Practice Address - Street 2:SUITE 970
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-235-8500
Practice Address - Fax:618-222-4618
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. ELIZABETH'S HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-10
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118809208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE43670Medicare UPIN