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RRC140034-01 ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS (Terminated)
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Main Details
Name
ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS
Subdivision Name
Behavioral Health - Angela Center
Type
Rural Referral Center
Rural
Yes
340B ID
RRC140034-01
Medicare Provider Number
140034
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/6/2015
Participating Start Date
1/1/2016
Participating Approval Date
11/9/2015
Last Recertification Date
8/19/2019
Termination Date
Termination Reason
4/1/2020
Site closure
Contacts
Authorizing Official
SSM Health - St. Mary's Hospital Centralia, IL
Damon Harbison, President
(618) 436-8000
Primary Contact
SSM Health
Jeffrey Peine, Finance Director
(314) 989-3532
Addresses
Street Address
444 N. Pleasant Avenue
Centralia, IL 62801
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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