Provider Demographics
NPI:1174702708
Name:ST MARYS HOSPITAL DECATUR OF THE HOSPITAL SISTERS OF THE THIRD ORDER
Entity type:Organization
Organization Name:ST MARYS HOSPITAL DECATUR 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:217-464-2966
Mailing Address - Fax:217-464-1039
Practice Address - Street 1:1900 E LAKE SHORE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3824
Practice Address - Country:US
Practice Address - Phone:217-464-1030
Practice Address - Fax:217-464-1039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty