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General NPI Number Information
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NPI Number | 1679270763
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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 | 02/09/2023
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Last Update Date | 02/09/2023
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Provider Practice Location Address
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Address Line | 3111 BROADWAY ST
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City | MOUNT VERNON
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State | IL
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Zip | 62864-2338
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Country | US
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Telephone | 618-241-0333
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Fax | 618-241-0334
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Provider Business Mailing Address
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Address Line | 3111 BROADWAY ST
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City | MOUNT VERNON
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State | IL
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Zip | 62864-2338
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Country | US
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Telephone | 618-241-0333
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Fax | 618-241-0334
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Authorized Official
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Title or Position | SECRETARY
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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 | 363LX0106X
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Taxonomy Name | Occupational Health Nurse Practitioner
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License Number |
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License Number State |
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