Basic Information
| Provider Information | |||||||||
| NPI: | 1174295224 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEACONESS SPECIALTY PHYSICIANS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1230 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477061230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124506815 | ||||||||
| FaxNumber: | 8124506822 | ||||||||
| Practice Location | |||||||||
| Address1: | 1103 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARMI | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628211380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188424617 | ||||||||
| FaxNumber: | 6183804565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2021 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | WATHEN | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | ANNETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY-TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 8124503296 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.