NPIMap

Organization Active NPI

Deaconess Memorial Medical Center Inc

Doing business as Dale Family Medicine

  • Family Medicine Physician
  • Dale, IN
National Provider Identifier
1174603153
Registry record updated Mar 16, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
DEACONESS MEMORIAL MEDICAL CENTER INC
Doing business as
Dale Family Medicine
Practice address
4 W Vine St
Dale, IN 47523
Phone
(812) 937-7140
Fax
(812) 937-7145
NPI assigned
Oct 16, 2006
Last updated
Mar 16, 2026By the provider in NPPES
Organization subpart
Yes
Parent organization
DEACONESS MEMORIAL MEDICAL CENTER INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 16, 2026

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

Authorized official

Name
Keith Miller
Title
Cao & Indiana Region President
Phone
(812) 996-0507

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X Primary
Rural Health Clinic/Center 261QR1300X
Nurse Practitioner 363L00000X

Addresses

Primary practice location

4 W Vine St
Dale, IN 47523

Mailing address

PO Box 1028
Jasper, IN 47547-1028
Phone (812) 996-8478

Other identifiers 2

IdentifierTypeStateIssuer
200282080AMedicaidIN
CB3118OtherKYRAILROAD MEDICARE

Other names 1

  • Dale Family Medicine Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031118000733 IN Part B Supplier - Clinic/Group Practice 4587578042 Receives reassigned benefits from 170 practitioners
36 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Jasper, IN; Shoals, IN; Loogootee, IN; Montgomery, IN; Petersburg, IN; Santa Claus, IN; Washington, IN; Dale, IN…
O20101124000873 IN Part A Provider - Rural Health Clinic 4587578042 Practice locations: Dale, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1174603153. Details of each certification follow.

Rural health clinic certification: CCN 153859

Legal name
DEACONESS MEMORIAL MEDICAL CENTER INC
Doing business as
DALE FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 7, 2000
Last certification
Oct 8, 2024
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jun 13, 1950 in IN
Enrollment address
4 W Vine Street
Dale, IN 47523-9061

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 36

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

View all 36

National Provider Directory

National Provider Directory
Part of
Memorial Hospital Healt

Ownership & related parties

All disclosed owners & managing parties 20

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Edward W Miller Individual Corporate DirectorBoard Member Feb 12, 2018
Tonya S Heim Individual Corporate DirectorBoard Member Sep 27, 2010
Lori Persohn Individual Corporate DirectorBoard Member Feb 1, 2019
Sharon Ann Walsh Individual Corporate DirectorBoard Member Jan 1, 2010
Renee Cunningham Individual Corporate DirectorBoard Member Jan 1, 2010
Brenda L Stallings Individual Corporate DirectorBoard Member Jan 1, 2013
Sohail Qadir Individual Corporate DirectorBoard Member Jul 1, 2015
James a Huebner Individual Corporate DirectorBoard Member Jan 1, 2014
Deaconess Memorial Medical Center Inc Organization, Jasper, IN Non-profit 5% Or Greater Direct Ownership Interest Jun 2, 2000 100%
Kenneth L Sendelweck Individual Corporate DirectorBoard Member Jan 1, 2010
Sherril Lueken Individual Corporate DirectorBoard Member Jul 1, 2015
Edward K Bennett Individual Corporate DirectorPresident and Ceo Mar 31, 2015
W-2 Managing Employee Aug 4, 1997
Kelly Clauss Individual Corporate DirectorBoard Member Apr 1, 2014
David N Dauby Individual Corporate DirectorBoard Member Jan 1, 2022
David Ryan Phillips Individual Corporate DirectorBoard Member Jan 1, 2022
Michael Kern Individual Corporate DirectorBoard Member Sep 2, 2021
Stanley J Tretter Individual Corporate DirectorBoard Member Apr 6, 2015
Mathew Gaug Individual Corporate Director Aug 1, 2019
Donna Balka Individual Corporate DirectorBoard Member May 1, 2021
Scott a Beckman Individual Corporate DirectorBoard Member Jan 1, 2010

Owners & managing parties with NPI records 10

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Mission Behavioral Health HospitalHuntingburg, IN, CCN 154072 Hospital 5% Or Greater Direct Ownership Interest (50%) Apr 5, 2024

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 13

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.

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1160956800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1773619200000",
    "number": "1174603153",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1028",
            "city": "JASPER",
            "state": "IN",
            "postal_code": "475471028",
            "telephone_number": "812-996-8478",
            "fax_number": "812-996-8497"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4 W VINE ST",
            "city": "DALE",
            "state": "IN",
            "postal_code": "47523",
            "telephone_number": "812-937-7140",
            "fax_number": "812-937-7145"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS MEMORIAL MEDICAL CENTER INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DEACONESS MEMORIAL MEDICAL CENTER INC",
        "enumeration_date": "2006-10-16",
        "last_updated": "2026-03-16",
        "certification_date": "2026-03-16",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "KEITH",
        "authorized_official_title_or_position": "CAO & INDIANA REGION PRESIDENT",
        "authorized_official_telephone_number": "812-996-0507"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200282080A",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "CB3118",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dale Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dale, IN

Sources for this page

Verify at the official NPI Registry.