Provider Demographics
NPI:1043874449
Name:STATERA HEALTH CARE, LLC
Entity type:Organization
Organization Name:STATERA HEALTH CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-833-1691
Mailing Address - Street 1:2250 N ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5612
Mailing Address - Country:US
Mailing Address - Phone:618-833-1691
Mailing Address - Fax:618-861-5302
Practice Address - Street 1:100 DR WARREN TUTTLE DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2718
Practice Address - Country:US
Practice Address - Phone:618-833-1691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-01
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty