Healthcare Provider Details

I. General information

NPI: 1326836206
Provider Name (Legal Business Name): DEACONESS ILLINOIS CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 LOGAN COLLEGE DRIVE J BUILDING
CARTERVILLE IL
62918
US

IV. Provider business mailing address

PO BOX 632330
CINCINNATI OH
45263-2330
US

V. Phone/Fax

Practice location:
  • Phone: 618-926-6698
  • Fax:
Mailing address:
  • Phone: 618-219-1311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KYLE DILLMAN
Title or Position: SECRETARY TREASURER
Credential:
Phone: 812-450-7399