Provider Demographics
NPI: | 1619123585 |
---|---|
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: | 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: | 812-426-9506 |
Mailing Address - Fax: | 812-434-7942 |
Practice Address - Street 1: | 421 CHESTNUT ST |
Practice Address - Street 2: | |
Practice Address - City: | EVANSVILLE |
Practice Address - State: | IN |
Practice Address - Zip Code: | 47713 |
Practice Address - Country: | US |
Practice Address - Phone: | 812-426-9506 |
Practice Address - Fax: | 812-434-7942 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2008-08-12 |
Last Update Date: | 2020-09-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 2080P0206X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | Group - Multi-Specialty |
No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
No | 231H00000X | Speech, Language and Hearing Service Providers | Audiologist | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
No | 363LA2100X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | Group - Multi-Specialty |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 7100051610 | Other | KY MEDICAID NP |
KY | 7100051640 | Other | KY MEDICAID PODIATRY |
IN | 200910900 | Medicaid | |
KY | 7100051590 | Other | KY MEDICAID PHYSICIAN |
KY | 7100051590 | Other | KY MEDICAID PHYSICIAN |
KY | 7100051640 | Other | KY MEDICAID PODIATRY |