1841763380 NPI number — DEACONESS SPECIALTY PHYSICIANS, INC

Table of content: (NPI 1841763380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841763380 NPI number — DEACONESS SPECIALTY PHYSICIANS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEACONESS SPECIALTY PHYSICIANS, 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:
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:
1841763380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1230
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:
47706-1230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-450-7899
Provider Business Mailing Address Fax Number:
812-450-6029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4551 SPRINGHILL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWENSBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42303-4671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-464-9133
Provider Business Practice Location Address Fax Number:
812-450-6029
Provider Enumeration Date:
01/08/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WATHEN
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
ANNETTE
Authorized Official Title or Position:
SECRETARY / TREASURER
Authorized Official Telephone Number:
812-450-3296

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X ; 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: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X ; 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" .

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