Basic Information
| Provider Information | |||||||||
| NPI: | 1841907409 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEACONESS ILLINOIS SPECIALTY CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEACONESS IL SPECIALTY GOOD SAMARITAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1 GOOD SAMARITAN WAY | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628642402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182424600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2022 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | DILLMAN | ||||||||
| AuthorizedOfficialFirstName: | KYLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 8124507399 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.