MEDICARE: DEACONESS HOSPITAL, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CG1119	OTHER	IN	RR MCARE GROUP #

General Provider Information

NPI Number	:	1023052883
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEACONESS HOSPITAL, INC

Provider Business Mailing Address
First Line	:	PO BOX 3407
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47733-3407
Country	:	US
Telephone Number	:	812-450-6815
Fax Number	:	812-450-6822

Provider Business Practice Location Address
First Line	:	105 N 2ND AVE
Second Line	:
City	:	PRINCETON
State	:	IN
Zip	:	47670-1005
Country	:	US
Telephone Number	:	812-386-6560
Fax Number	:	812-385-5015

Authorized Official
Title or Position	:	SR VICE PRESIDENT, CFO
Name	:	RICHARD M STIVERS
Credential	:
Telephone Number	:	812-450-3296

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	10/19/2007

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Directions to “DEACONESS HOSPITAL, INC ” Practice Location

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