Provider Demographics
NPI:1699921585
Name:DEACONESS CLINIC INC.
Entity type:Organization
Organization Name:DEACONESS CLINIC INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WATHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-450-3296
Mailing Address - Street 1:PO BOX 3868
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47737-3868
Mailing Address - Country:US
Mailing Address - Phone:812-649-5061
Mailing Address - Fax:812-649-5224
Practice Address - Street 1:3434 W STATE ROAD 66
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:IN
Practice Address - Zip Code:47635-9259
Practice Address - Country:US
Practice Address - Phone:812-649-5061
Practice Address - Fax:812-649-5224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200910900Medicaid
KY7100051640OtherKY MEDICAID PODIATRY
KY7100051610OtherKY MEDICAID NP
KY7100051590OtherKY MEDICAID PHYSICIANS
IN257900Medicare PIN