Provider Demographics
NPI:1407800998
Name:DEACONESS HOSPITAL, INC
Entity Type:Organization
Organization Name:DEACONESS HOSPITAL, INC
Other - Org Name:DEACONESS RILEY CHILDREN'S SPECIALTY CLINIC
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 3407
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47733-3407
Mailing Address - Country:US
Mailing Address - Phone:812-858-3131
Mailing Address - Fax:812-858-3140
Practice Address - Street 1:4133 GATEWAY BLVD
Practice Address - Street 2:STE 220
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-7953
Practice Address - Country:US
Practice Address - Phone:812-858-3131
Practice Address - Fax:812-858-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Multi-Specialty
No2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Multi-Specialty
No2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric NephrologyGroup - Multi-Specialty
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
No2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric RheumatologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200296920BMedicaid
IN200296920BMedicaid
IN=========-042OtherTRICARE