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Organization
ST. MARY'S HOSPITAL
Active
Organization
ST. MARY'S HOSPITAL
Active
Parent organization
ST. MARY'S HOSPITAL
Other names
St. Mary's Vascular and Thoracic Surgery
Organization subpart
Yes
Provider details
NPI number
Legal business name
ST. MARY'S HOSPITAL
Authorized official
KAREN S CLARK (CFO)
(815) 673-4514
Entity
Organization
Contact information
Practice address
104 E BRIDGE ST, STREATOR, IL 61364-2967
(815) 672-4015
Mailing address
104 E BRIDGE ST, STREATOR, IL 61364-2967
(815) 672-4015
Taxonomy
Speciality
Code
Description
License number
State
2086S0129X
Vascular Surgery Physician
Primary
036078501
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1548281926
MD NPI
—
05
—
36121627
—
IL
01
—
5032121
BLUESHIELD
IL
01
—
IL1789
MEDICARE GROUP
IL
Enumeration date
11/19/2007
Last updated
05/13/2009
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