Provider Demographics
NPI:1710098405
Name:DEACONESS HOSPITAL, INC
Entity Type:Organization
Organization Name:DEACONESS HOSPITAL, INC
Other - Org Name:DEACONESS MEDICAL GROUP - PETERSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT, CFO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:STIVERS
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:812-450-6815
Mailing Address - Fax:812-450-6822
Practice Address - Street 1:106 W PIKE AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47567-8750
Practice Address - Country:US
Practice Address - Phone:812-354-1052
Practice Address - Fax:812-354-8280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN153843OtherRURAL HEALTH #
INCG1119OtherRR MCARE GROUP #
IN640440Medicare ID - Type UnspecifiedMCARE GROUP #
INCG1119OtherRR MCARE GROUP #
IN153843OtherRURAL HEALTH #
IN153843Medicare PIN