Provider Demographics
NPI:1689821134
Name:ST. MARY'S HOSPITAL
Entity Type:Organization
Organization Name:ST. MARY'S HOSPITAL
Other - Org Name:ST. MARY'S HEALTH CARE
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 1:1640 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350
Mailing Address - Country:US
Mailing Address - Phone:815-431-9208
Mailing Address - Fax:
Practice Address - Street 1:1640 1ST AVE
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350
Practice Address - Country:US
Practice Address - Phone:815-431-9208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-26
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002659282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1760453187OtherMD NPI
IL5015121OtherBLUESHIELD
1942238589OtherMD NPI
ILIL1789OtherMEDICARE GROUP
IL127OtherBLUE CROSS
ILIL1789004OtherMEDICARE PTAN