Provider Demographics
NPI:1255391611
Name:ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS
Entity type:Organization
Organization Name:ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:
Authorized Official - Phone:618-436-8000
Mailing Address - Street 1:1195 CORPORATE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-1716
Mailing Address - Country:US
Mailing Address - Phone:314-989-3524
Mailing Address - Fax:314-989-3695
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
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:2006-03-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002642273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL154401OtherHEALTH ALLIANCE
IL154401OtherHEALTH ALLIANCE