NPIMap

Organization Active NPI

Deaconess Clinic, Inc

Doing business as Deaconess Clinic, I

  • Family Medicine Physician
  • Oakland City, IN
National Provider Identifier
1396040374
Registry record updated Aug 10, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
DEACONESS CLINIC, INC
Doing business as
Deaconess Clinic, I
Practice address
1204 Williams St.
Oakland City, IN 47660-1001
Phone
(812) 749-6187
Fax
(812) 749-4966
NPI assigned
Jan 21, 2011
Last updated
Aug 10, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 10, 2017

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 3

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

Addresses

Primary practice location

1204 Williams St.
Oakland City, IN 47660-1001

Mailing address

PO Box 1510
Evansville, IN 47706-1510
Phone (812) 749-6187

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
O20221013000945 IN Part A Provider - Rural Health Clinic 3375610116 Practice locations: Oakland City, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1396040374. Details of each certification follow.

Rural health clinic certification: CCN 153936

Legal name
DEACONESS CLINIC INC
Doing business as
DEACONESS CLINIC OAKLAND CITY
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 13, 2023
Last certification
Sep 13, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 2008 in IN
Enrollment address
1204 Williams St
Oakland City, IN 47660-1001

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
15D0361297Deaconess Clinic - Oakland City1204 Williams St, Oakland City, IN 47660Certificate of waiverDec 11, 2027

National Provider Directory

National Provider Directory

Locations

1204 Williams St
Oakland City, IN 47660
Phone (812) 749-6187

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 3

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": "1295568000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1502323200000",
    "number": "1396040374",
    "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": "812-749-6187",
            "fax_number": "812-749-4966"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1204 WILLIAMS ST.",
            "city": "OAKLAND CITY",
            "state": "IN",
            "postal_code": "476601001",
            "telephone_number": "812-749-6187",
            "fax_number": "812-749-4966"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS CLINIC, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-01-21",
        "last_updated": "2017-08-10",
        "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": "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
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Deaconess Clinic, I",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Oakland City, IN

Sources for this page

Verify at the official NPI Registry.