MEDICARE: DEACONESS ILLINOIS SPECIALTY CLINIC, 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	363L00000X	Nurse Practitioner
2	207RI0011X	Interventional Cardiology Physician

General Provider Information

NPI Number	:	1386351849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEACONESS ILLINOIS SPECIALTY CLINIC, INC.

Provider Business Mailing Address
First Line	:	PO BOX 34266
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-0620
Country	:	US
Telephone Number	:	812-450-6815
Fax Number	:	812-450-6822

Provider Business Practice Location Address
First Line	:	1028 S KIRKWOOD RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-7222
Country	:	US
Telephone Number	:	314-287-6184
Fax Number	:	314-394-2253

Authorized Official
Title or Position	:	SECRETARY TREASURER
Name	:	KYLE DILLMAN
Credential	:
Telephone Number	:	812-450-7399

Provider Enumeration Date	:	11/03/2022
Last Update Date	:	01/26/2023

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