Basic Information
| Provider Information | |||||||||
| NPI: | 1972210235 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEACONESS ILLINOIS SPECIALTY CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHERN ILLINOIS VEIN CLINIC | ||||||||
| 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: | 3331 W DEYOUNG ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629595896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189987155 | ||||||||
| FaxNumber: | 6189987285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2022 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | DILLMAN | ||||||||
| AuthorizedOfficialFirstName: | KYLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| 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 | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 208C00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.