NPIMap

Organization Active NPI

St Elizabeths Hospital of the Hospital Sisters of the Third Order

Doing business as O'Fallon Family Medicine Center

  • Family Medicine Physician
  • O'Fallon, IL
National Provider Identifier
1104849165
Registry record updated Oct 31, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
ST ELIZABETHS HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER
Doing business as
O'Fallon Family Medicine Center
Practice address
1512 N Green Mount Rd
Suite 108
O Fallon, IL 62269-1953
Phone
(618) 624-5510
Fax
(618) 624-5525
NPI assigned
Jul 25, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 31, 2024

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

Authorized official

Name
Mark D Evard
Title
VP of Revenue Cycle
Phone
(217) 492-9651

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

1512 N Green Mount Rd
Suite 108
O Fallon, IL 62269-1953

Mailing address

3051 Hollis Dr
Springfield, IL 62704-7450
Phone (618) 624-5510

Other names 1

  • O'Fallon Family Medicine Center Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address hshs_st_elizabeth_ofallon2202617@ewd.direct.hshs.org Direct

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031212000629 IL Part B Supplier - Clinic/Group Practice 6406753011 Receives reassigned benefits from 38 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: O Fallon, IL

Other NPIs on the same Medicare enrollment 7

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

NPI Registry JSON

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

{
    "created_epoch": "1153785600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730332800000",
    "number": "1104849165",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3051 HOLLIS DR",
            "city": "SPRINGFIELD",
            "state": "IL",
            "postal_code": "627047450",
            "telephone_number": "618-624-5510",
            "fax_number": "618-624-5525"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1512 N GREEN MOUNT RD",
            "address_2": "SUITE 108",
            "city": "O FALLON",
            "state": "IL",
            "postal_code": "622691953",
            "telephone_number": "618-624-5510",
            "fax_number": "618-624-5525"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST ELIZABETHS HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-25",
        "last_updated": "2024-10-31",
        "certification_date": "2024-10-31",
        "status": "A",
        "authorized_official_last_name": "EVARD",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "VP OF REVENUE CYCLE",
        "authorized_official_telephone_number": "217-492-9651"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "hshs_st_elizabeth_ofallon2202617@ewd.direct.hshs.org",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CDA/CCD/TXT",
            "address_1": "1 Saint Elizabeth Blvd",
            "city": "O Fallon",
            "state": "IL",
            "country_code": "US",
            "postal_code": "622691099",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "O'Fallon Family Medicine Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "O'Fallon Family Medicine Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in O'Fallon, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.