MEDICARE: DEACONESS ILLINOIS CROSSROADS 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

General Provider Information

NPI Number	:	1528785284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEACONESS ILLINOIS CROSSROADS INC

Provider Business Mailing Address
First Line	:	PO BOX 34142
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-0619
Country	:	US
Telephone Number	:	812-450-6815
Fax Number	:	812-450-6822

Provider Business Practice Location Address
First Line	:	1209 W ROBINSON ST
Second Line	:
City	:	WAYNE CITY
State	:	IL
Zip	:	62895-9672
Country	:	US
Telephone Number	:	618-895-2050
Fax Number	:	618-895-2056

Authorized Official
Title or Position	:	CFO
Name	:	AMBER LIPE
Credential	:
Telephone Number	:	618-998-7020

Provider Enumeration Date	:	10/24/2022
Last Update Date	:	08/07/2024

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