Provider Demographics
NPI:1710969563
Name:ST JOHN'S HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST F
Entity Type:Organization
Organization Name:ST JOHN'S HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST F
Other - Org Name:ST. JOHN'S HOME INFUSION PROGRAM
Other - Org Type:Other Name
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:217-544-6464
Mailing Address - Fax:217-535-3989
Practice Address - Street 1:801 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5323
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:217-535-3989
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOHN'S HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-17
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL093013360251F00000X
IL032006022251F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========008Medicaid
IL0459110001Medicare NSC