Healthcare Provider Details

I. General information

NPI: 1063104206
Provider Name (Legal Business Name): DEACONESS ILLINOIS CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 05/25/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411 PROFESSIONAL PARK DR
MARION IL
62959-6394
US

IV. Provider business mailing address

PO BOX 34156
BELFAST ME
04915-0619
US

V. Phone/Fax

Practice location:
  • Phone: 618-969-8630
  • Fax: 618-969-8639
Mailing address:
  • Phone: 812-450-6815
  • Fax: 812-450-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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