Healthcare Provider Details

I. General information

NPI: 1154036259
Provider Name (Legal Business Name): DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3331 W DEYOUNG ST STE 101
MARION IL
62959-5896
US

IV. Provider business mailing address

3331 W DEYOUNG ST STE 101
MARION IL
62959-5896
US

V. Phone/Fax

Practice location:
  • Phone: 618-998-7169
  • Fax: 618-998-7533
Mailing address:
  • Phone: 618-998-7169
  • Fax: 618-998-7533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SX0106X
TaxonomyOccupational Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

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