NPIMap

Organization Active NPI

Deaconess Illinois Clinic, Inc

  • Family Medicine Physician
  • Marion, IL
National Provider Identifier
1063104206
Registry record updated Jul 15, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
DEACONESS ILLINOIS CLINIC, INC
Practice address
3411 Professional Park Dr
Marion, IL 62959-6394
Phone
(618) 969-8630
Fax
(618) 969-8639
NPI assigned
May 25, 2023
Last updated
Jul 15, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 15, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Kyle Dillman
Title
Secretary
Phone
(812) 450-7399

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X NU
Nurse Practitioner 363L00000X NU
Family Medicine Physician 207Q00000X NU Primary
Pediatrics Physician 208000000X NU

Addresses

Primary practice location

3411 Professional Park Dr
Marion, IL 62959-6394

Mailing address

PO Box 632330
Cincinnati, OH 45263-2330
Phone (812) 450-6815

Other names 1

  • Deaconess Illinois Clinic 3411 Professional Park Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230220002667 IL Part B Supplier - Clinic/Group Practice 5092187021 Receives reassigned benefits from 33 practitioners
10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Marion, IL; Waterloo, IL; Mount Vernon, IL; Harrisburg, IL; Columbia, IL; Carterville, IL; Benton, IL

Other NPIs on the same Medicare enrollment 10

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

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
14D2190844Deaconess Illinois Clinic3411 Professional Park Dr, Marion, IL 62959Certificate of waiverAug 18, 2026

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1684972800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1784073600000",
    "number": "1063104206",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 632330",
            "city": "CINCINNATI",
            "state": "OH",
            "postal_code": "452632330",
            "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": "3411 PROFESSIONAL PARK DR",
            "city": "MARION",
            "state": "IL",
            "postal_code": "629596394",
            "telephone_number": "618-969-8630",
            "fax_number": "618-969-8639"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS ILLINOIS CLINIC, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-05-25",
        "last_updated": "2026-07-15",
        "certification_date": "2026-07-15",
        "status": "A",
        "authorized_official_last_name": "DILLMAN",
        "authorized_official_first_name": "KYLE",
        "authorized_official_title_or_position": "SECRETARY",
        "authorized_official_telephone_number": "812-450-7399",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Deaconess Illinois Clinic 3411 Professional Park",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Marion, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2026; 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.