Healthcare Provider Details

I. General information

NPI: 1760986392
Provider Name (Legal Business Name): DEACONESS SPECIALTY PHYSICIANS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 COLLEGE DR
MOUNT CARMEL IL
62863
US

IV. Provider business mailing address

PO BOX 1230
EVANSVILLE IN
47706-1230
US

V. Phone/Fax

Practice location:
  • Phone: 812-450-7899
  • Fax: 812-450-6029
Mailing address:
  • Phone: 812-450-7899
  • Fax: 812-450-6029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: CHERYL A WATHEN
Title or Position: SECRETARY/TREASURER
Credential:
Phone: 812-450-3296