Healthcare Provider Details

I. General information

NPI: 1093000283
Provider Name (Legal Business Name): DEACONESS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 08/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 UNIVERSITY BLVD ROOM HP0091
EVANSVILLE IN
47712-3534
US

IV. Provider business mailing address

PO BOX 1510
EVANSVILLE IN
47706-1510
US

V. Phone/Fax

Practice location:
  • Phone: 812-465-1250
  • Fax: 812-465-7170
Mailing address:
  • Phone: 812-465-1250
  • Fax: 812-465-7170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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