NPIMap

Organization Active NPI

Deaconess Illinois Specialty Clinic, Inc.

Doing business as Deaconess Care Group Illinois Union County

  • Hospitalist Physician
  • Anna, IL
National Provider Identifier
1225858251
Registry record updated Oct 15, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Hospitalist PhysicianTaxonomy code 208M00000X
Legal business name
DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Doing business as
Deaconess Care Group Illinois Union County
Practice address
517 N Main St
Anna, IL 62906-1668
Phone
(618) 833-4511
NPI assigned
Oct 15, 2024
Last updated
Oct 15, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 15, 2024

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

Authorized official

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

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X
Nurse Practitioner 363L00000X
Hospitalist Physician 208M00000X Primary

Addresses

Primary practice location

517 N Main St
Anna, IL 62906-1668

Mailing address

PO Box 632331
Cincinnati, OH 45263-2331
Phone (618) 833-4511

Other names 1

  • Deaconess Care Group Illinois Union County Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230321001688 IL Part B Supplier - Clinic/Group Practice 9830562016 Receives reassigned benefits from 243 practitioners
23 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Marion, IL; West Frankfort, IL; Waterloo, IL; Salem, IL; Red Bud, IL; Mount Vernon, IL; Benton, IL; Harrisburg, IL…

Other NPIs on the same Medicare enrollment 23

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

View all 23

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
14D2317473Deaconess Illinois Specialty Clinic517 N Main St, Anna, IL 62906Certificate of waiverJan 23, 2027

National Provider Directory

National Provider Directory
Tax ID family
Deaconess Illinois Specialty Clinic Inc19 organizations share this tax ID, including this one

Other organizations with this tax ID 18

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

View all 18

Practitioners & affiliated clinicians

Practitioners 217

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 217

NPI Registry JSON

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

{
    "created_epoch": "1728950400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1728950400000",
    "number": "1225858251",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 632331",
            "city": "CINCINNATI",
            "state": "OH",
            "postal_code": "452632331",
            "telephone_number": "618-833-4511"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "517 N MAIN ST",
            "city": "ANNA",
            "state": "IL",
            "postal_code": "629061668",
            "telephone_number": "618-833-4511"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS ILLINOIS SPECIALTY CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-10-15",
        "last_updated": "2024-10-15",
        "certification_date": "2024-10-15",
        "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"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208M00000X",
            "taxonomy_group": "",
            "desc": "Hospitalist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Deaconess Care Group Illinois Union County",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Anna, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 2024; 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.