Healthcare Provider Details

I. General information

NPI: 1902781644
Provider Name (Legal Business Name): DEACONESS MEMORIAL MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W 13TH ST STE 225
JASPER IN
47546-1817
US

IV. Provider business mailing address

800 W 9TH ST
JASPER IN
47546-2514
US

V. Phone/Fax

Practice location:
  • Phone: 812-996-7388
  • Fax: 812-996-5933
Mailing address:
  • Phone: 812-996-1088
  • Fax: 812-996-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: KEITH MILLER
Title or Position: CAO - INDIANA REGION PRESIDENT
Credential:
Phone: 812-996-0507