Provider Demographics
NPI:1407804602
Name:DEACONESS CLINIC, INC
Entity Type:Organization
Organization Name:DEACONESS CLINIC, INC
Other - Org Name:DEACONESS COMP CENTER GATEWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-450-2250
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:812-450-7455
Mailing Address - Fax:812-450-2960
Practice Address - Street 1:4011 GATEWAY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8947
Practice Address - Country:US
Practice Address - Phone:812-858-2100
Practice Address - Fax:812-858-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200191200BMedicaid
INCG0999Medicare PIN
IN5407580001Medicare NSC
IN131250Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER