Provider Demographics
NPI:1770687196
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:CFO
Authorized Official - Phone:618-436-6205
Mailing Address - Street 1:1145 CORPORATE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-2907
Mailing Address - Country:US
Mailing Address - Phone:314-989-2492
Mailing Address - Fax:314-344-7281
Practice Address - Street 1:400 N PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3056
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:2006-09-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002642207P00000X, 207RI0011X, 208100000X, 2084N0400X, 2085R0001X, 2085R0202X, 227800000X, 227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGroup - Single Specialty
No227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL35110OtherGROUP HEALTH PLAN
IL6110182OtherBLUE CROSS BLUE SHIELD
IL247625OtherHEALTHLINK NUMBER
IL=========001OtherTRICARE PROVIDER NUMBER
IL6110182OtherBLUE CROSS BLUE SHIELD
IL=========001OtherTRICARE PROVIDER NUMBER