Provider Demographics
NPI:1952496176
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
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:618-523-4216
Mailing Address - Fax:618-523-7049
Practice Address - Street 1:205 MUNSTER STREET
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:IL
Practice Address - Zip Code:62245
Practice Address - Country:US
Practice Address - Phone:618-523-4216
Practice Address - Fax:618-523-7049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1656Medicare Oscar/Certification
IL143918Medicare Oscar/Certification
IL148502Medicare Oscar/Certification