Basic Information
| Provider Information | |||||||||
| NPI: | 1336152156 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEACONESS HOSPITAL, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | USI STUDENT HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3407 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477333407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124506815 | ||||||||
| FaxNumber: | 8124506822 | ||||||||
| Practice Location | |||||||||
| Address1: | 8600 UNIVERSITY BLVD | ||||||||
| Address2: | RM HP0091 | ||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477123534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124651250 | ||||||||
| FaxNumber: | 8124657170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 09/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 8124502250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100272080K | 05 | IN | MEDICAID | CG1119 | 01 | IN | RR MCARE GROUP # | OTHER |