Healthcare Provider Details

I. General information

NPI: 1730896291
Provider Name (Legal Business Name): DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2022
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 RICKER RD
SALEM IL
62881-4263
US

IV. Provider business mailing address

PO BOX 34266
BELFAST ME
04915-0620
US

V. Phone/Fax

Practice location:
  • Phone: 182-418-7916
  • Fax: 618-244-1926
Mailing address:
  • Phone: 812-450-6815
  • Fax: 812-450-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

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