1700966777 NPI number — DEACONESS MEMORIAL MEDICAL CENTER INC

Table of content: (NPI 1700966777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700966777 NPI number — DEACONESS MEMORIAL MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEACONESS MEMORIAL MEDICAL CENTER 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:
1700966777
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 W 9TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JASPER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47546-2514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
812-481-8497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FERDINAND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47532-9534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-367-1906
Provider Business Practice Location Address Fax Number:
812-367-2487
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
CAO & INDIANA REGION PRESIDENT
Authorized Official Telephone Number:
812-969-0507

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200048850B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: CB3118 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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