Healthcare Provider Details

I. General information

NPI: 1639502859
Provider Name (Legal Business Name): DEACONESS CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 WARRICK DR
BOONVILLE IN
47601-8602
US

IV. Provider business mailing address

PO BOX 1510
EVANSVILLE IN
47706-1510
US

V. Phone/Fax

Practice location:
  • Phone: 812-858-3355
  • Fax: 812-858-3350
Mailing address:
  • Phone: 812-450-6879
  • Fax: 812-858-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHERYL A WATHEN
Title or Position: CFO
Credential:
Phone: 812-450-3296