Basic Information
| Provider Information | |||||||||
| NPI: | 1629162573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEACONESS HOSPITAL, INC | ||||||||
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| OtherOrganizationName: | DEACONESS ANESTHESIA SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3366 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477323366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124502240 | ||||||||
| FaxNumber: | 8124502710 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 MARY ST | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477470001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124502240 | ||||||||
| FaxNumber: | 8124502710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/06/2017 | ||||||||
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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 | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 200350410 | 05 | IN | MEDICAID | 65935694 | 05 | KY | MEDICAID |