Healthcare Provider Details

I. General information

NPI: 1588477855
Provider Name (Legal Business Name): DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 DOCTORS PARK RD
MOUNT VERNON IL
62864-6224
US

IV. Provider business mailing address

PO BOX 632331
CINCINNATI OH
45263-2331
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-1380
  • Fax: 618-244-1380
Mailing address:
  • Phone: 618-244-1380
  • Fax: 618-244-1380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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