Provider Demographics
NPI:1164673307
Name:ST MARYS HOSPITAL
Entity type:Organization
Organization Name:ST MARYS HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-673-4514
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:815-673-3223
Mailing Address - Fax:815-673-3305
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:815-673-3223
Practice Address - Fax:815-673-3305
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST MARYS HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-07
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070970207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1659330090OtherMD NPI
IL9924600OtherCIGNA
IL036070970Medicaid
IL1164673307OtherBLUESHIELD
IL1164673307OtherBLUESHIELD