Provider Demographics
NPI:1154036259
Name:DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Entity type:Organization
Organization Name:DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-450-7399
Mailing Address - Street 1:3331 W DEYOUNG ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5896
Mailing Address - Country:US
Mailing Address - Phone:618-998-7169
Mailing Address - Fax:618-998-7533
Practice Address - Street 1:3331 W DEYOUNG ST STE 101
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5896
Practice Address - Country:US
Practice Address - Phone:618-998-7169
Practice Address - Fax:618-998-7533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No364SX0106XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOccupational HealthGroup - Multi-Specialty