Basic Information
| Provider Information | |||||||||
| NPI: | 1558766790 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEACONESS CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1510 | ||||||||
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| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477061510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124506815 | ||||||||
| FaxNumber: | 8124506822 | ||||||||
| Practice Location | |||||||||
| Address1: | 1808 SHERMAN DR | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476701043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124252646 | ||||||||
| FaxNumber: | 8128584586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2014 | ||||||||
| LastUpdateDate: | 02/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | WATHEN | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8124503296 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 207Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.