1417905688 NPI number — DEACONESS CLINIC, INC

Table of content: (NPI 1417905688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417905688 NPI number — DEACONESS CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEACONESS CLINIC, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DEACONESS COMP CENTER NORTHPARK
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417905688
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
329 W COLUMBIA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47710-1757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-450-7455
Provider Business Mailing Address Fax Number:
812-450-2960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4506 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47710-3624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-428-6161
Provider Business Practice Location Address Fax Number:
812-421-2883
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
812-450-2250

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QX0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200191200A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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