Basic Information
| Provider Information | |||||||||
| NPI: | 1548986839 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEACONESS ILLINOIS CROSSROADS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 MARY ST | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477101658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124506815 | ||||||||
| FaxNumber: | 8124506822 | ||||||||
| Practice Location | |||||||||
| Address1: | 4119 S WATER TOWER PL STE A | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628646293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182469595 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2022 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | STIMPSON | ||||||||
| AuthorizedOfficialFirstName: | JARED | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 8124508287 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.