Basic Information
| Provider Information | |||||||||
| NPI: | 1659527935 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEACONESS CLINIC INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEACONESS CLINIC II | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1510 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477061510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124506815 | ||||||||
| FaxNumber: | 8124506822 | ||||||||
| Practice Location | |||||||||
| Address1: | 685 VAIL STREET | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476709510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123866650 | ||||||||
| FaxNumber: | 8123855015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 02/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | STIVERS | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8124503296 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100051590 | 01 | KY | KY MEDICAID PHYSICIANS | OTHER | 7100051640 | 01 | KY | KY MEDICAID PODIATRY | OTHER | 200910700 | 05 | IN | MEDICAID | 7100051610 | 01 | KY | KY MEDICAID NP | OTHER |