NPIMap

Organization Active NPI

St Mary's Hospital, Centralia, Illinois

Doing business as SSM Health St. Mary's Hospital - Centralia

  • General Acute Care Hospital
  • Centralia, IL
National Provider Identifier
1083617245
Registry record updated Nov 27, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Acute Care HospitalTaxonomy code 282N00000X
License
0002642 Issued in IL
Legal business name
ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS
Doing business as
SSM Health St. Mary's Hospital - Centralia
Practice address
400 N Pleasant Ave
Centralia, IL 62801
Phone
(618) 436-8000
NPI assigned
May 23, 2005
Last updated
Nov 27, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 27, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Damon R Harbison
Title
President
Phone
(618) 436-8000

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Hospital Unit 273R00000X 0002642 IL
General Acute Care Hospital 282N00000X 0002642 IL Primary

Addresses

Primary practice location

400 N Pleasant Ave
Centralia, IL 62801

Mailing address

1195 Corporate Lake Dr
Saint Louis, MO 63132-1716
Phone (314) 989-3524

Other identifiers 6

IdentifierTypeStateIssuer
003578OtherILHEALTH ALLIANCE
0182OtherILBLUE CROSS BLUE SHIELD
133046300OtherILACS OWCP
105814OtherILHEALTHLINK
30045800OtherILBLACK LUNG
35110OtherILGROUP HEALTH PLAN

Other names 1

  • SSM Health St. Mary's Hospital - Centralia Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20071110000096 IL Part A Provider - Hospital 6709788920 Practice locations: Centralia, IL; Salem, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1083617245. Details of each certification follow.

Hospital certification: CCN 140034

Legal name
ST MARYS HOSPITAL CENTRALIA ILLINOIS
Doing business as
SSM HEALTH ST. MARY'S HOSPITAL - CENTRALIA
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Oct 20, 2006
Beds
125
Ownership / control type
Church
Organization structure
CorporationNon-profit
Incorporated
Sep 12, 1947 in IL
Enrollment address
400 N Pleasant Ave
Centralia, IL 62801-3056
Other Hospital Practice Location
Hospital subgroups
General

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Hospital

Medicare Care Compare
Listed as
SSM Health St Mary's Hospital -CentraliaCCN 140034 · All quality measures
Overall star rating
3 of 5
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Church
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory
Tax ID family
SRHC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 18

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Jeremy Midura Individual Corporate DirectorBoard Member Dec 31, 2022
Susan Niepoetter Individual Corporate DirectorBoard Member Sep 14, 2024
Paula Friedman Individual Corporate DirectorBoard Member Dec 31, 2022
Damon R Harbison Individual Corporate DirectorPresident, Ex-Officio Jun 1, 2018
Operational/Managerial ControlPresident Jun 1, 2018
Eric Ibendahl Individual Corporate Director Jan 1, 2022
Suzie Schmidt Individual Corporate DirectorBoard Member Dec 31, 2021
Rajendra Shroff Individual Corporate DirectorBoard Member Mar 16, 2023
Jeremy M Fotheringham Individual Corporate OfficerRegional President Jan 1, 2023
SSM Health Care Corporation Organization, Saint Louis, MO Non-profit 5% Or Greater Indirect Ownership Interest Sep 1, 2015 100%
Monica Heinzman Individual Corporate DirectorBoard Member Sep 14, 2023
Eileen Lamm Individual Corporate OfficerRegional Vice President Finance Mar 23, 2020
Operational/Managerial ControlRegional Vice President Finance Mar 23, 2020
Matthew Flanigan Individual Corporate Director Jan 1, 2022
Sudeep Nair Individual Corporate Director Jan 1, 2022
Timothy Buller Individual Corporate OfficerRegional Cfo-Financial Strategy Oct 1, 2015
Operational/Managerial ControlRegional Cfo - Financial Strategy Oct 1, 2015
SSM Regional Health Services Organization, Saint Louis, MO Non-profit 5% Or Greater Direct Ownership Interest Sep 1, 2015 100%
Tena Hoyt Individual Corporate Director Jan 1, 2022
Jean-Benoit Houle Individual Corporate DirectorBoard Member Dec 31, 2022
Patricia Williams Individual Corporate DirectorBoard Member Nov 1, 2015

Owners & managing parties with NPI records 17

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

View all 17

Facilities with the same owner 30

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 30

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 304

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 304

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1116806400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1701043200000",
    "number": "1083617245",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1195 CORPORATE LAKE DR",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631321716",
            "telephone_number": "314-989-3524",
            "fax_number": "314-989-3695"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 N PLEASANT AVE",
            "city": "CENTRALIA",
            "state": "IL",
            "postal_code": "62801",
            "telephone_number": "618-436-8000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST MARY'S HOSPITAL, CENTRALIA, ILLINOIS",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-05-23",
        "last_updated": "2023-11-27",
        "status": "A",
        "authorized_official_last_name": "HARBISON",
        "authorized_official_first_name": "DAMON",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "618-436-8000",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "273R00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Unit",
            "state": "IL",
            "license": "0002642",
            "primary": false
        },
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": "IL",
            "license": "0002642",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTH ALLIANCE",
            "identifier": "003578",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "0182",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ACS OWCP",
            "identifier": "133046300",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTHLINK",
            "identifier": "105814",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLACK LUNG",
            "identifier": "30045800",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP HEALTH PLAN",
            "identifier": "35110",
            "state": "IL"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1068.1",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "2720 Dundee Rd # 302",
            "city": "Northbrook",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600622609",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "SSM Health St. Mary's Hospital - Centralia",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "SSM Health St. Mary's Hospital - Centralia",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Centralia, IL

Sources for this page

Verify at the official NPI Registry.