Provider Demographics
NPI:1003159997
Name:DEACONESS CLINIC, INC
Entity Type:Organization
Organization Name:DEACONESS CLINIC, INC
Other - Org Name:DEACONESS CLINIC I
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WATHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-450-3296
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1510
Mailing Address - Country:US
Mailing Address - Phone:270-827-4596
Mailing Address - Fax:270-826-2838
Practice Address - Street 1:1035 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2712
Practice Address - Country:US
Practice Address - Phone:270-827-4596
Practice Address - Fax:270-826-2838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-29
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100051620Medicaid