Provider Demographics
NPI:1629003074
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:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARBISON
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:618-436-8000
Mailing Address - Fax:
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
Practice Address - Country:US
Practice Address - Phone:618-436-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002642261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6123830OtherBLUE CROSS BLUE SHIELD
IL=========005OtherTRICARE WSI
IL=========016OtherTRICARE WSI
IL=========013OtherTRICARE WSI
IL=========005OtherTRICARE WSI