Healthcare Provider Details

I. General information

NPI: 1003523374
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: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4117 S WATER TOWER PL STE C
MOUNT VERNON IL
62864-6567
US

IV. Provider business mailing address

PO BOX 34266
BELFAST ME
04915-0620
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-0672
  • Fax: 618-242-0862
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
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

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