Provider Demographics
NPI:1639502859
Name:DEACONESS CLINIC, INC
Entity Type:Organization
Organization Name:DEACONESS CLINIC, INC
Other - Org Name:DEACONESS CLINIC I
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 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:812-450-6879
Mailing Address - Fax:812-858-4586
Practice Address - Street 1:3150 WARRICK DR
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-8602
Practice Address - Country:US
Practice Address - Phone:812-858-3355
Practice Address - Fax:812-858-3350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty