Healthcare Provider Details

I. General information

NPI: 1831345792
Provider Name (Legal Business Name): DEACONESS CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 08/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 W PIKE AVE
PETERSBURG IN
47567-8750
US

IV. Provider business mailing address

PO BOX 1510
EVANSVILLE IN
47706-1510
US

V. Phone/Fax

Practice location:
  • Phone: 812-354-1052
  • Fax: 812-354-8280
Mailing address:
  • Phone: 812-354-1052
  • Fax: 812-354-8280

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 Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

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