Healthcare Provider Details

I. General information

NPI: 1811788862
Provider Name (Legal Business Name): DEACONESS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2025
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 W 9TH ST
JASPER IN
47546-2609
US

IV. Provider business mailing address

PO BOX 631767
CINCINNATI OH
45263-2767
US

V. Phone/Fax

Practice location:
  • Phone: 812-996-7474
  • Fax: 812-886-0653
Mailing address:
  • Phone: 812-450-6879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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