NPIMap

Organization Active NPI

St. Mary'S Hospital, Centralia, Illinois

  • Comprehensive Outpatient Rehabilitation Facility (CORF)
  • Centralia, IL
National Provider Identifier
1710105192
Registry record updated Nov 27, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Comprehensive Outpatient Rehabilitation Facility (CORF)Taxonomy code 261QR0401X
License
0002642 Issued in IL
Legal business name
ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS
Practice address
400 N Pleasant Ave
Centralia, IL 62801
Phone
(618) 436-8000
NPI assigned
Apr 23, 2007
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) 436-6205

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Comprehensive Outpatient Rehabilitation Facility (CORF) 261QR0401X 0002642 IL Primary

Addresses

Primary practice location

400 N Pleasant Ave
Centralia, IL 62801

Mailing address

PO Box 503861
Saint Louis, MO 63150-0001
Phone (618) 436-8000

Other identifiers 1

IdentifierTypeStateIssuer
6123830OtherILBLUE CROSS BLUE SHIELD

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

National Provider Directory

National Provider Directory

Member of 1

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

Locations

1445 W Broadway
Centralia, IL 62801

402 N Pleasant Ave
Centralia, IL 62801
Phone (618) 436-6180

1054 Martin Luther King Dr
Ste 224
Centralia, IL 62801
Phone (618) 436-5231

1052 Martin Luther King Dr
Ste 100
Centralia, IL 62801
Phone (618) 436-6479

1250 W Whittaker St
Ste B
Salem, IL 62881
Phone (618) 548-3769

Practitioners & affiliated clinicians

Practitioners 385

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 385

NPI Registry JSON

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

{
    "created_epoch": "1177286400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1701043200000",
    "number": "1710105192",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 503861",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631500001",
            "telephone_number": "618-436-8000"
        },
        {
            "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": "2007-04-23",
        "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": "618-436-6205",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QR0401X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)",
            "state": "IL",
            "license": "0002642",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "6123830",
            "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

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 27, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.