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General NPI Number Information
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NPI Number | 1629785183
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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 | 11/03/2022
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Last Update Date | 01/26/2023
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Provider Practice Location Address
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Address Line | 205 BAILEY LN STE F
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City | BENTON
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State | IL
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Zip | 62812-1921
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Country | US
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Telephone | 618-882-4200
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Fax | 618-882-4208
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Provider Business Mailing Address
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Address Line | PO BOX 34266
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City | BELFAST
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State | ME
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Zip | 04915-0620
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Country | US
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Telephone | 812-450-6815
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Fax | 812-450-6822
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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 | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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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 | 208600000X
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Taxonomy Name | Surgery Physician
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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 | 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 #4
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number |
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License Number State |
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