Deaconess Illinois Specialty Clinic, Inc.
Organization Active NPI Nurse Practitioner · Mount Vernon, IL
NPI 1497462964 · NPPES record last updated Jan 26, 2023
Key facts
- NPI
- 1497462964
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Nurse Practitioner 363L00000X
- Legal business name
- DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
- Practice address
- 3111 Broadway St
Mount Vernon, IL 62864-2338 - Phone
- (618) 241-0300
- Fax
- (618) 241-0302
- NPI assigned
- Nov 3, 2022
- Organization subpart
- No
Authorized official
- Name
- Kyle Dillman
- Title
- Secretary Treasurer
- Phone
- (812) 450-7399
Other NPIs on the same Medicare enrollment 23
Practitioners 11
-
Maliha Khan, M.D.
-
Debabrata Ray, MD
-
Lowell Grey Sensintaffar, M.D.
-
Billie J Toland, FNP-BC
-
Diana Vaughn, FNP-C
-
Milton Antonio Roldan, NP-C
-
Cody Sullivan, MD
-
Fahd Abdullah Kader Syed, M.D., M.P.H.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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… |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Sports Medicine (Family Medicine) Physician |
207QS0010X | |||
| Nurse Practitioner |
363L00000X | Yes |
Addresses
Primary practice location
3111 Broadway St
Mount Vernon, IL 62864-2338
Mailing address
PO Box 34266
Belfast, ME 04915-0620
Phone (812) 450-6815
Other names
- Deaconess IL Specialty Express Broadway St
Other providers in Mount Vernon, IL
- Deaconess Illinois Crossroads Inc
- Deaconess Illinois Crossroads Inc
- Deaconess Illinois Specialty Clinic, Inc.
- Deaconess Illinois Specialty Clinic, Inc.
- Deaconess Illinois Specialty Clinic, Inc.
- Deaconess Illinois Specialty Clinic, Inc.
- Deaconess Illinois Specialty Clinic, Inc.
- Deaconess Illinois Specialty Clinic, Inc.
- David L Deloso
- Vivian V Deloso
All providers in Mount Vernon, IL · Nurse Practitioner in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 26, 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.