Basic Information
Provider Information | |||||||||
NPI: | 1073220349 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DEACONESS ILLINOIS SPECIALTY CLINIC, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DEACONESS IL SPECIALTY BROADWAY ST | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 MARY ST | ||||||||
Address2: |   | ||||||||
City: | EVANSVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 477101658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124506815 | ||||||||
FaxNumber: | 8124506822 | ||||||||
Practice Location | |||||||||
Address1: | 818 E BROADWAY ST | ||||||||
Address2: |   | ||||||||
City: | SPARTA | ||||||||
State: | IL | ||||||||
PostalCode: | 622861820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6189394200 | ||||||||
FaxNumber: | 6189394256 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/04/2022 | ||||||||
LastUpdateDate: | 11/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DILLMAN | ||||||||
AuthorizedOfficialFirstName: | KYLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY TREASURER | ||||||||
AuthorizedOfficialTelephone: | 8124507399 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207RI0011X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.