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	363L00000X	Nurse Practitioner
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1962857813
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEACONESS MEMORIAL MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	800 W 9TH ST
Second Line	:
City	:	JASPER
State	:	IN
Zip	:	47546-2514
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3644 E COUNTY ROAD 1600 N
Second Line	:
City	:	LINCOLN CITY
State	:	IN
Zip	:	47552-9662
Country	:	US
Telephone Number	:	812-937-6021
Fax Number	:

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

Provider Enumeration Date	:	04/28/2016
Last Update Date	:	08/27/2025

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