Provider Demographics
NPI:1104849165
Name:ST ELIZABETHS HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER
Entity type:Organization
Organization Name:ST ELIZABETHS HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
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:618-624-5510
Mailing Address - Fax:618-624-5525
Practice Address - Street 1:1512 N GREEN MOUNT RD
Practice Address - Street 2:SUITE 108
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1953
Practice Address - Country:US
Practice Address - Phone:618-624-5510
Practice Address - Fax:618-624-5525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212826Medicare ID - Type Unspecified