Deaconess Illinois Clinic, Inc
Organization Active NPI Family Medicine Physician · Harrisburg, IL
NPI 1285350504 · NPPES record last updated Jul 28, 2023
Key facts
- NPI
- 1285350504
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- DEACONESS ILLINOIS CLINIC, INC
- Practice address
- 303 S Commercial St
Harrisburg, IL 62946-2125 - Phone
- (618) 918-6060
- Fax
- (618) 294-8238
- NPI assigned
- Oct 18, 2022
- Organization subpart
- No
Authorized official
- Name
- Kyle Dillman
- Title
- Secretary Treasurer
- Phone
- (812) 450-7399
Other NPIs on the same Medicare enrollment 10
Corporate family (same tax ID) 20
Practitioners 22
-
Dennon W Davis, M.D.
-
Maryanne F Flint, FNP
-
Jodi L Fox, M.D.
-
Eric Sean Graham, MD
-
Amy Zeller, PA-C
-
Lara Enid Smith, MD
-
Bayly Lynn Adams, APRN
-
Dietra Leigh Angelly, FNP-C
-
Terri Lynn Braddock-Hartman, APRN, BC
-
Angela Catherine Burns, MSN, FNP-C
-
Sherri K Parr, PA-C
-
Kara Tipsword, FNP-C
-
Shanna Witges, APRN NP-C
-
Jordan Maria Smith, FNP
-
Nicky R Turner, FNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
- Tax ID family
- Deaconess Illinois Clinic
Locations
1306 N Russell St
Marion, IL 62959
Phone (618) 997-2248
4105 N Water Tower Pl
Mount Vernon, IL 62864
Phone (618) 244-9495
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes | ||
| Nurse Practitioner |
363L00000X |
Addresses
Primary practice location
303 S Commercial St
Harrisburg, IL 62946-2125
Mailing address
PO Box 34156
Belfast, ME 04915-0619
Phone (812) 450-6815
Other names
- Deaconess IL Clinic 303 Commercial St
Other providers in Harrisburg, IL
- Benna Kaye Daugherty
- Christina Rae Davis
- Danielle Davis
- Deborah Davis
- Karsyn Davis
- Deaconess Illinois Clinic, Inc
- Deaconess Illinois Specialty Clinic, Inc.
- Deaconess Illinois Specialty Clinic, Inc.
- Deaconess Regional Healthcare Services Illinois Inc
- Leanne H Deneal
All providers in Harrisburg, IL · Family Medicine Physician in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 28, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.