Provider Demographics
NPI:1598946543
Name:ST. MARY'S HOSPITAL
Entity Type:Organization
Organization Name:ST. MARY'S HOSPITAL
Other - Org Name:ST. MARY'S VASCULAR AND THORACIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-673-4514
Mailing Address - Street 1:104 E BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2967
Mailing Address - Country:US
Mailing Address - Phone:815-672-4015
Mailing Address - Fax:
Practice Address - Street 1:104 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2967
Practice Address - Country:US
Practice Address - Phone:815-672-4015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-19
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360785012086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36121627Medicaid
1548281926OtherMD NPI
ILIL1789OtherMEDICARE GROUP
IL5032121OtherBLUESHIELD
ILIL1789OtherMEDICARE GROUP