=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053514943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEACONESS CLINIC, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2007
-----------------------------------------------------
Last Update Date | 02/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 329 W COLUMBIA ST
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47710-1757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-450-7455
-----------------------------------------------------
Fax | 812-450-2960
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 329 W COLUMBIA ST
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47710-1757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-450-7455
-----------------------------------------------------
Fax | 812-450-2960
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | LINDA E WHITE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 812-450-2250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number | 28172540A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------