NPIMap

Organization Active NPI

St. Mary's Hospital, Centralia, Illinois

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

  • Anesthesiology Physician
  • Centralia, IL
National Provider Identifier
1477097871
Registry record updated Mar 26, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Anesthesiology PhysicianTaxonomy code 207L00000X
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 62801-3056
Phone
(618) 436-6056
Fax
(618) 532-9365
NPI assigned
Dec 5, 2016
Last updated
Mar 26, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 26, 2018

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

Authorized official

Name
Mr. Tim Buller, CFO
Title
Regional Cfo
Phone
(314) 989-2492

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Anesthesiology Physician 207L00000X 0002642 IL Primary
Pain Medicine (Anesthesiology) Physician 207LP2900X 0002642 IL

Addresses

Primary practice location

400 N Pleasant Ave
Centralia, IL 62801-3056

Mailing address

1145 Corporate Lake Dr
Saint Louis, MO 63132-2907
Phone (314) 989-2492

Other names 1

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

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040127000118 IL Part B Supplier - Clinic/Group Practice 6709788920 Receives reassigned benefits from 395 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Centralia, IL

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 152

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.

View all 152

NPI Registry JSON

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

{
    "created_epoch": "1480896000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1522022400000",
    "number": "1477097871",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1145 CORPORATE LAKE DR",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631322907",
            "telephone_number": "314-989-2492",
            "fax_number": "314-344-7281"
        },
        {
            "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": "628013056",
            "telephone_number": "618-436-6056",
            "fax_number": "618-532-9365"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-12-05",
        "last_updated": "2018-03-26",
        "status": "A",
        "authorized_official_last_name": "BULLER",
        "authorized_official_first_name": "TIM",
        "authorized_official_title_or_position": "REGIONAL CFO",
        "authorized_official_telephone_number": "314-989-2492",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CFO"
    },
    "taxonomies": [
        {
            "code": "207L00000X",
            "taxonomy_group": "",
            "desc": "Anesthesiology",
            "state": "IL",
            "license": "0002642",
            "primary": true
        },
        {
            "code": "207LP2900X",
            "taxonomy_group": "",
            "desc": "Anesthesiology, Pain Medicine",
            "state": "IL",
            "license": "0002642",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SSM Health St. Mary's Hospital - Centralia",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Centralia, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 26, 2018; 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.