NPIMap

Organization Active NPI

Deaconess Memorial Medical Center Inc

Doing business as Cullen Medical Professionals

  • Family Medicine Physician
  • Washington, IN
National Provider Identifier
1598058414
Registry record updated Aug 27, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
DEACONESS MEMORIAL MEDICAL CENTER INC
Doing business as
Cullen Medical Professionals
Practice address
2005 State St
Suite a
Washington, IN 47501-8558
Phone
(812) 254-4650
Fax
(812) 254-4081
NPI assigned
May 25, 2011
Organization subpart
Yes
Parent organization
DEACONESS MEMORIAL MEDICAL CENTER INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 27, 2025

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

Authorized official

Name
Keith Miller
Title
Cao & Indiana Region President
Phone
(812) 960-5079

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207Q00000X Primary
Rural Health Clinic/Center 261QR1300X

Addresses

Primary practice location

2005 State St
Suite a
Washington, IN 47501-8558

Mailing address

800 W 9TH St
Jasper, IN 47546-2514

Other names 1

  • Cullen Medical Professionals Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031118000733 IN Part B Supplier - Clinic/Group Practice 4587578042 Receives reassigned benefits from 170 practitioners
36 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Jasper, IN; Shoals, IN; Loogootee, IN; Montgomery, IN; Petersburg, IN; Santa Claus, IN; Washington, IN; Dale, IN…
O20110809000393 IN Part A Provider - Rural Health Clinic 4587578042 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Montgomery, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1598058414. Details of each certification follow.

Rural health clinic certification: CCN 153871

Legal name
DEACONESS MEMORIAL MEDICAL CENTER INC
Doing business as
COUNTRY HEALTH CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 30, 2004
Last certification
Jun 28, 2022
Ownership / control type
2B
Most recent change of ownership
Jul 1, 2011 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Jun 13, 1950 in IN
Enrollment address
5066 N 900 E
Montgomery, IN 47558-5790

Other NPIs on the same Medicare enrollment 36

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

View all 36

National Provider Directory

National Provider Directory
Part of
The Little Company of Mar

Locations

522 S Maple St
French Lick, IN 47432
Phone (812) 936-6400

507 E 19th St
Huntingburg, IN 47542
Phone (812) 683-1891

1950 Saint Charles St
Ste 4
Jasper, IN 47546
Phone (812) 482-9555

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Tonya S Heim Individual Corporate DirectorBoard Member Jan 1, 2013
Kristi M Nord Individual Corporate DirectorBoard Member Jan 1, 2024
Renee Cunningham Individual Corporate DirectorBoard Member Jan 1, 2013
Sohail Qadir Individual Corporate DirectorBoard Member Jul 1, 2015
Shannon Ebenkamp Individual W-2 Managing EmployeeDirector of Finance Oct 8, 2024
James a Huebner Individual Corporate DirectorBoard Member Jan 1, 2014
Deaconess Health System Inc Organization, Evansville, IN Corporation, Chain home office 5% Or Greater Direct Ownership Interest Feb 1, 2024 100%
Lynn C Lingafelter Individual Corporate DirectorBoard Member Feb 1, 2024
Christian Blome Individual Corporate DirectorBoard Member Feb 1, 2024
Shawn W McCoy Individual 5% Or Greater Direct Ownership Interest Feb 1, 2024 100%
Operational/Managerial Control Feb 1, 2024
Keith Miller Individual Corporate OfficerCao & Indiana Region President Oct 8, 2024
W-2 Managing EmployeeAd; Oct 8, 2024
James Porter Individual Corporate DirectorBoard Member Feb 1, 2024
Donna Balka Individual Corporate DirectorBoard Member May 1, 2021
Nicholas a Werne Individual Corporate DirectorBoard Member Aug 5, 2022

Owners & managing parties with NPI records 3

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

NPI Registry JSON

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

{
    "created_epoch": "1306281600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1756252800000",
    "number": "1598058414",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "800 W 9TH ST",
            "city": "JASPER",
            "state": "IN",
            "postal_code": "475462514"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2005 STATE ST",
            "address_2": "SUITE A",
            "city": "WASHINGTON",
            "state": "IN",
            "postal_code": "475018558",
            "telephone_number": "812-254-4650",
            "fax_number": "812-254-4081"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS MEMORIAL MEDICAL CENTER INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DEACONESS MEMORIAL MEDICAL CENTER INC",
        "enumeration_date": "2011-05-25",
        "last_updated": "2025-08-27",
        "certification_date": "2025-08-27",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "KEITH",
        "authorized_official_title_or_position": "CAO & INDIANA REGION PRESIDENT",
        "authorized_official_telephone_number": "812-960-5079"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Cullen Medical Professionals",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Washington, IN

Sources for this page

Verify at the official NPI Registry.