MEDICARE: DEACONESS MEMORIAL MEDICAL CENTER 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	261QR1300X	Rural Health Clinic/Center
2	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CB3118	OTHER	KY	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174603153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEACONESS MEMORIAL MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	PO BOX 1028
Second Line	:
City	:	JASPER
State	:	IN
Zip	:	47547-1028
Country	:	US
Telephone Number	:	812-996-8478
Fax Number	:	812-996-8497

Provider Business Practice Location Address
First Line	:	4 W VINE ST
Second Line	:
City	:	DALE
State	:	IN
Zip	:	47523
Country	:	US
Telephone Number	:	812-937-7140
Fax Number	:	812-937-7145

Authorized Official
Title or Position	:	CAO & INDIANA REGION PRESIDENT
Name	:	KEITH MILLER
Credential	:
Telephone Number	:	812-996-0507

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	08/27/2025

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