Basic Information
| Provider Information | |||||||||
| NPI: | 1497187397 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEACONESS HOSPITAL, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEACONESS SLEEP CENTER EAST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3407 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477333407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124731737 | ||||||||
| FaxNumber: | 8124506747 | ||||||||
| Practice Location | |||||||||
| Address1: | 7307 E COLUMBIA ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124731737 | ||||||||
| FaxNumber: | 8124506747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2013 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WATHEN | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8124503296 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 2084S0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 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 | 363LA2100X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 207RS0012X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200226410I | 05 | IN | MEDICAID |