Provider Demographics
NPI: | 1083472369 |
---|---|
Name: | DEACONESS CLINIC, INC. |
Entity Type: | Organization |
Organization Name: | DEACONESS CLINIC, INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CFO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CHERYL |
Authorized Official - Middle Name: | ANNETTE |
Authorized Official - Last Name: | WATHEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 812-450-3296 |
Mailing Address - Street 1: | PO BOX 3366 |
Mailing Address - Street 2: | |
Mailing Address - City: | EVANSVILLE |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 47732-3366 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 812-450-6815 |
Mailing Address - Fax: | 812-450-6822 |
Practice Address - Street 1: | 801 FELSTEAD RD |
Practice Address - Street 2: | |
Practice Address - City: | EVANSVILLE |
Practice Address - State: | IN |
Practice Address - Zip Code: | 47712-3607 |
Practice Address - Country: | US |
Practice Address - Phone: | 812-450-6879 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2024-03-11 |
Last Update Date: | 2024-03-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty |