Healthcare Provider Details

I. General information

NPI: 1417674185
Provider Name (Legal Business Name): DEACONESS ILLINOIS CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 W DEYOUNG ST STE G
MARION IL
62959-4943
US

IV. Provider business mailing address

PO BOX 34156
BELFAST ME
04915-0619
US

V. Phone/Fax

Practice location:
  • Phone: 618-969-8663
  • Fax: 618-969-8639
Mailing address:
  • Phone: 812-450-6815
  • Fax: 812-450-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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