=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275456105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEACONESS KENTUCKY CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2026
-----------------------------------------------------
Last Update Date | 07/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 W 18TH ST
-----------------------------------------------------
City | HOPKINSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42240-1965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-450-6815
-----------------------------------------------------
Fax | 812-450-6822
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 632817
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45263-2817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | KYLE DILLMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 812-450-7399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------