Basic Information
| Provider Information | |||||||||
| NPI: | 1114173499 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEACONESS CLINIC, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEACONESS CLINIC I | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1510 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477061510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124506815 | ||||||||
| FaxNumber: | 8124506822 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 W COLUMBIA ST | ||||||||
| Address2: | STE 440 | ||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477101782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124252461 | ||||||||
| FaxNumber: | 8124247254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 11/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | STIVERS | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8124503296 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.