Healthcare Provider Details

I. General information

NPI: 1972877280
Provider Name (Legal Business Name): DEACONESS MEMORIAL MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6402 E INDUSTRIAL LANE
LEAVENWORTH IN
47137-8316
US

IV. Provider business mailing address

P O BOX 1028
JASPER IN
47547-1028
US

V. Phone/Fax

Practice location:
  • Phone: 877-291-6488
  • Fax:
Mailing address:
  • Phone: 812-996-8476
  • Fax: 812-996-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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