Provider Demographics
NPI:1710375977
Name:ST JOSEPHS HOSPITAL BREESE OF THE HOSPITAL SISTERS OF THE THIRD ORDER
Entity Type:Organization
Organization Name:ST JOSEPHS HOSPITAL BREESE OF THE HOSPITAL SISTERS OF THE THIRD ORDER
Other - Org Name:CLINTON COUNTY RURAL HEALTH CARLYLE
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:DUANE
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:618-594-8924
Mailing Address - Fax:618-594-7918
Practice Address - Street 1:14509 STATE ROUTE 127
Practice Address - Street 2:
Practice Address - City:CARLYLE
Practice Address - State:IL
Practice Address - Zip Code:62231-6485
Practice Address - Country:US
Practice Address - Phone:618-594-8924
Practice Address - Fax:618-594-7918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
148554Medicare Oscar/Certification