Basic Information
| Provider Information | |||||||||
| NPI: | 1659441483 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEACONESS HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEACONESS HOME MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 MARY ST | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477470001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124504673 | ||||||||
| FaxNumber: | 8124504665 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 GARFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477101771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124504673 | ||||||||
| FaxNumber: | 8124504665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 09/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | CAMP | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8124506148 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | 69000101A | IN | N | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 3336H0001X | 60001691A | IN | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 251F00000X | 69000101A | IN | Y | Agencies | Home Infusion |
ID Information
| ID | Type | State | Issuer | Description | 200424320A | 05 | IN | MEDICAID | 90234451 | 05 | KY | MEDICAID | 35059390401 | 05 | IL | MEDICAID |