NPIMap

Organization Active NPI

Deaconess Clinic, Inc

  • Rural Health Clinic/Center
  • Fort Branch, IN
National Provider Identifier
1285880179
Registry record updated Dec 7, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
DEACONESS CLINIC, INC
Practice address
802 E Oak St
Fort Branch, IN 47648-1666
Phone
(812) 753-3942
Fax
(812) 768-6283
NPI assigned
Aug 12, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 7, 2023

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

Authorized official

Name
Cheryl A Wathen
Title
Cfo
Phone
(812) 450-3296

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

802 E Oak St
Fort Branch, IN 47648-1666

Mailing address

PO Box 1510
Evansville, IN 47706-1510
Phone (812) 753-3942

Other names 1

  • Deaconess Clinic I Doing business as

Medicare participation

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

Enrollment records 2

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
O20221013001591 IN Part A Provider - Rural Health Clinic 3375610116 Practice locations: Fort Branch, IN

Rural health clinic certification: CCN 153933

Legal name
DEACONESS CLINIC INC
Doing business as
DEACONESS CLINIC FT. BRANCH
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 22, 2023
Last certification
Aug 22, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 2008 in IN
Enrollment address
802 E Oak St
Fort Branch, IN 47648-1666

Other NPIs with the same Medicare PAC ID 9

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

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
15D0923906Deaconess Clinic Inc/Ft Branch802 E Oak St, Fort Branch, IN 47648Certificate of waiverJul 24, 2027

National Provider Directory

National Provider Directory
Tax ID family
Deaconess Clinc Inc99 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Ownership & related parties

All disclosed owners & managing parties 15

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

NameRoleSinceShare
Mia Souheil Hindi Individual Corporate Director Oct 1, 2015
Garrett C Koon Individual Corporate Director Oct 1, 2020
Ashley Lynn Richeson Individual Corporate Director Oct 1, 2020
Deaconess Health System Inc Organization, Evansville, IN Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jul 1, 2008 100%
Snesha Modi Individual Corporate Director Oct 1, 2020
William R Smith Individual Corporate Director Oct 1, 2015
Jason F White Individual Corporate Director Oct 1, 2022
Barry S Phillips Individual Corporate Director Oct 1, 2015
Jamie L Mull Individual Corporate Director Oct 1, 2021
Cheryl Wathen Individual Corporate OfficerCfo Oct 1, 2012
W-2 Managing EmployeeCfo Oct 1, 2012
Stephen T Titzer Individual Corporate Director Oct 1, 2012
Shawn W McCoy Individual Corporate OfficerCeo Oct 1, 2017
W-2 Managing EmployeeCeo Oct 1, 2017
Chris E Chacko Individual Corporate Director Oct 1, 2019
Gary J Keepes Individual Corporate Director Oct 1, 2019
Dhruvin Mehta Individual Corporate Director Oct 1, 2022

Owners & managing parties with NPI records 11

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

Facilities with the same owner 28

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

View all 28

Practitioners & affiliated clinicians

Practitioners 411

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

View all 411

NPI Registry JSON

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

{
    "created_epoch": "1218499200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1701907200000",
    "number": "1285880179",
    "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": "812-753-3942",
            "fax_number": "812-768-6283"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "802 E OAK ST",
            "city": "FORT BRANCH",
            "state": "IN",
            "postal_code": "476481666",
            "telephone_number": "812-753-3942",
            "fax_number": "812-768-6283"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS CLINIC, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-08-12",
        "last_updated": "2023-12-07",
        "certification_date": "2023-12-07",
        "status": "A",
        "authorized_official_last_name": "WATHEN",
        "authorized_official_first_name": "CHERYL",
        "authorized_official_middle_name": "A",
        "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": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Deaconess Clinic I",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Deaconess Clinic I",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fort Branch, IN

Sources for this page

Verify at the official NPI Registry.