Healthcare Provider Details

I. General information

NPI: 1972210235
Provider Name (Legal Business Name): DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2022
Last Update Date: 05/23/2026
Certification Date: 05/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3331 W DEYOUNG ST
MARION IL
62959-5896
US

IV. Provider business mailing address

PO BOX 34266
BELFAST ME
04915-0620
US

V. Phone/Fax

Practice location:
  • Phone: 618-998-7155
  • Fax: 618-998-7285
Mailing address:
  • Phone: 812-450-6815
  • Fax: 812-450-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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