Provider Demographics
NPI:1770710360
Name:ST MARYS HOSPITAL
Entity type:Organization
Organization Name:ST MARYS HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, PFS
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-673-4603
Mailing Address - Street 1:104 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2899
Mailing Address - Country:US
Mailing Address - Phone:815-672-7289
Mailing Address - Fax:815-672-2891
Practice Address - Street 1:104 W 6TH ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2899
Practice Address - Country:US
Practice Address - Phone:815-672-7289
Practice Address - Fax:815-672-2891
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST MARYS HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-22
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL002659208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1952392557OtherPHYSICIAN NPI
IL36081908Medicaid
1124085758OtherMD INDIVIDUAL NPI
1851349435OtherMD INDIVIDUAL NPI
IL36113590Medicaid
IL36104105Medicaid
1851349435OtherMD INDIVIDUAL NPI
IL36081908Medicaid
IL36104105Medicaid
ILIL1789Medicare PIN