Provider Demographics
NPI:1003523374
Name:DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Entity Type:Organization
Organization Name:DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Other - Org Name:DEACONESS IL SPECIALTY 4117 WATER TOWER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-450-7399
Mailing Address - Street 1:PO BOX 34266
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-0620
Mailing Address - Country:US
Mailing Address - Phone:812-450-6815
Mailing Address - Fax:812-450-6822
Practice Address - Street 1:4117 S WATER TOWER PL STE C
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6567
Practice Address - Country:US
Practice Address - Phone:618-242-0672
Practice Address - Fax:618-242-0862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-04
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty