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RRC140034-06 ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS (Terminated)
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Main Details
Name
ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS
Subdivision Name
SMGS Centralia ENT
Type
Rural Referral Center
Rural
Yes
340B ID
RRC140034-06
Medicare Provider Number
140034
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/12/2017
Participating Start Date
7/1/2017
Participating Approval Date
5/1/2017
Last Recertification Date
9/11/2020
Termination Date
Termination Reason
7/1/2021
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
1054 Martin Luther King Jr. Drive, Suite 105
Centralia, IL 62801
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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