Healthcare Provider Details

I. General information

NPI: 1093143216
Provider Name (Legal Business Name): DEACONESS CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2013
Last Update Date: 08/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6221 PHYSICIANS CT SUITE 1
EVANSVILLE IN
47715-4031
US

IV. Provider business mailing address

PO BOX 1510
EVANSVILLE IN
47706-1510
US

V. Phone/Fax

Practice location:
  • Phone: 812-479-3153
  • Fax: 812-473-8166
Mailing address:
  • Phone: 812-479-3153
  • Fax: 812-473-8166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
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