Provider Demographics
NPI:1861420689
Name:DEACONESS MEMORIAL MEDICAL CENTER INC
Entity type:Organization
Organization Name:DEACONESS MEMORIAL MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAO & INDIANA REGION PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-996-0507
Mailing Address - Street 1:800 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-2514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:721 W 13TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1855
Practice Address - Country:US
Practice Address - Phone:812-481-5780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEACONESS MEMORIAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-29
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCB3118OtherRAILROAD MEDICARE
IN200048850CMedicaid
IN137600Medicare PIN
IN213110Medicare PIN