1033365986 NPI number — DEACONESS CLINIC INC.

Table of content: (NPI 1033365986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033365986 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:
Provider Other Organization Name Type Code:
6
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:
1033365986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1510
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:
47706-1510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-426-6638
Provider Business Mailing Address Fax Number:
812-450-8109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4233 GATEWAY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWBURGH
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47630-8900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-426-6638
Provider Business Practice Location Address Fax Number:
812-450-8109
Provider Enumeration Date:
08/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WATHEN
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
812-450-3296

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X ; 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: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0122X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200910900 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100051640 . This is a "KY MEDICAID PODIATRY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100318210 . This is a "KENTUCKY MEDICAID PHYSICIAN ASSISTANCE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100302340 . This is a "KY MEDICAID NURSE PRACTITIONER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100302450 . This is a "KY MEDICAID PHYSICIANS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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