Healthcare Provider Details

I. General information

NPI: 1235787425
Provider Name (Legal Business Name): DEACONESS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4949 HEALTHY WAY STE D
EVANSVILLE IN
47715-1180
US

IV. Provider business mailing address

329 W COLUMBIA ST
EVANSVILLE IN
47710-1757
US

V. Phone/Fax

Practice location:
  • Phone: 812-450-7455
  • Fax: 812-450-2960
Mailing address:
  • Phone: 812-450-7455
  • Fax: 812-450-2960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine 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 TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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