Basic Information
Provider Information | |||||||||
NPI: | 1366830259 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DEACONESS HOSPITAL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FREEDOM MEDICAL WEST | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 ARY ST | ||||||||
Address2: |   | ||||||||
City: | EVANSVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 477470001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124504673 | ||||||||
FaxNumber: | 8124504665 | ||||||||
Practice Location | |||||||||
Address1: | 2309 W FRANKLIN ST | ||||||||
Address2: |   | ||||||||
City: | EVANSVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 477125118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124219112 | ||||||||
FaxNumber: | 8124219132 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/31/2014 | ||||||||
LastUpdateDate: | 12/31/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHITE | ||||||||
AuthorizedOfficialFirstName: | LINDA | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 8124502250 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.