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General NPI Number Information
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NPI Number | 1588477855
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Entity Type | Organization
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Legal Business Name | DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
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Dates
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Enumeration Date | 01/30/2025
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Last Update Date | 01/31/2025
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Provider Practice Location Address
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Address Line | 8 DOCTORS PARK RD
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City | MOUNT VERNON
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State | IL
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Zip | 62864-6224
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Country | US
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Telephone | 618-244-1380
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Fax | 618-244-1380
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Provider Business Mailing Address
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Address Line | PO BOX 632331
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City | CINCINNATI
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State | OH
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Zip | 45263-2331
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Country | US
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Telephone | 618-244-1380
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Fax | 618-244-1380
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Authorized Official
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Title or Position | SECRETARY / TREASURER
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Name | KYLE DILLMAN
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Credential |
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Telephone | 812-450-7399
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number |
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License Number State |
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