Healthcare Provider Details

I. General information

NPI: 1407428519
Provider Name (Legal Business Name): DEACONESS SPECIALITY PHYSICIANS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SE 4TH ST
EVANSVILLE IN
47708-1607
US

IV. Provider business mailing address

PO BOX 1230
EVANSVILLE IN
47706-1230
US

V. Phone/Fax

Practice location:
  • Phone: 812-426-6638
  • Fax: 812-858-6802
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: CHERYL ANNETTE WATHEN
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 812-450-3296