NPIMap

Organization Active NPI

Deaconess Clinic, Inc.

  • Clinic/Center
  • Evansville, IN
National Provider Identifier
1013519396
Registry record updated Apr 7, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
DEACONESS CLINIC, INC.
Practice address
645 Connie Robinson Way
Evansville, IN 47713-1822
Phone
(812) 450-8764
Fax
(124) 012-1178
NPI assigned
Nov 12, 2020
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Cheryl Annette Wathen
Title
Cfo
Phone
(812) 450-3296

Corporate family (same tax ID) 12

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
15D2215179Deaconess Clinic Memorial645 Connie Robinson Way, Evansville, IN 47713Certificate of waiverNov 30, 2026

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Medicare enrollment records 1

Medicare enrollment files
Enrollment IDStateProvider typePAC IDDetails
O20080922000145 IN Part B Supplier - Clinic/Group Practice 3375610116 Receives reassigned benefits from 477 practitioners
This NPI is an additional NPI on the enrollment

National Provider Directory

National Provider Directory
Tax ID family
Deaconess Clinc Inc (99 organizations share this tax ID)

Locations

811 E Baseline Rd
Evansville, IN 47725
Phone (812) 867-7256

Specialties & licenses 4

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Clinic/Center 261Q00000X Primary
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X

Addresses

NPPES NPI Registry

Primary practice location

645 Connie Robinson Way
Evansville, IN 47713-1822

Mailing address

PO Box 1510
Evansville, IN 47706-1510
Phone (812) 450-6815

Other names 1

NPPES NPI Registry
  • Deaconess Clinic - Memorial Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Apr 7, 2021.

{
    "created_epoch": "1605139200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1617753600000",
    "number": "1013519396",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1510",
            "city": "EVANSVILLE",
            "state": "IN",
            "postal_code": "477061510",
            "telephone_number": "812-450-6815",
            "fax_number": "812-450-6822"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "645 CONNIE ROBINSON WAY",
            "city": "EVANSVILLE",
            "state": "IN",
            "postal_code": "477131822",
            "telephone_number": "812-450-8764",
            "fax_number": "124-012-1178"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-11-12",
        "last_updated": "2021-04-07",
        "certification_date": "2021-04-07",
        "status": "A",
        "authorized_official_last_name": "WATHEN",
        "authorized_official_first_name": "CHERYL",
        "authorized_official_middle_name": "ANNETTE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "812-450-3296"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Deaconess Clinic - Memorial",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Evansville, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 7, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.