NPIMap

Organization Active NPI

Deaconess Illinois Specialty Clinic, Inc.

Doing business as Deaconess IL Specialty Burns Ave

  • Interventional Cardiology Physician
  • Sparta, IL
National Provider Identifier
1619684172
Registry record updated Jan 26, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Interventional Cardiology PhysicianTaxonomy code 207RI0011X
Legal business name
DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Doing business as
Deaconess IL Specialty Burns Ave
St. Louis Cardiovascular
Practice address
205 S Burns Ave
Sparta, IL 62286-1867
Phone
(618) 443-2858
Fax
(618) 939-4256
NPI assigned
Nov 3, 2022
Last updated
Jan 26, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 26, 2023

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

Authorized official

Name
Kyle Dillman
Title
Secretary Treasurer
Phone
(812) 450-7399

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Interventional Cardiology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RI0011X Primary
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X
Medical Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363AM0700X
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X

Addresses

Primary practice location

205 S Burns Ave
Sparta, IL 62286-1867

Mailing address

PO Box 34266
Belfast, ME 04915-0620
Phone (812) 450-6815

Other names 2

  • Deaconess IL Specialty Burns Ave Doing business as
  • St. Louis Cardiovascular Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
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…

Other NPIs on the same Medicare enrollment 23

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

View all 23

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 5

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": "1667433600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1674691200000",
    "number": "1619684172",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 34266",
            "city": "BELFAST",
            "state": "ME",
            "postal_code": "049150620",
            "telephone_number": "812-450-6815",
            "fax_number": "812-450-6822"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "205 S BURNS AVE",
            "city": "SPARTA",
            "state": "IL",
            "postal_code": "622861867",
            "telephone_number": "618-443-2858",
            "fax_number": "618-939-4256"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS ILLINOIS SPECIALTY CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-11-03",
        "last_updated": "2023-01-26",
        "certification_date": "2023-01-26",
        "status": "A",
        "authorized_official_last_name": "DILLMAN",
        "authorized_official_first_name": "KYLE",
        "authorized_official_title_or_position": "SECRETARY TREASURER",
        "authorized_official_telephone_number": "812-450-7399"
    },
    "taxonomies": [
        {
            "code": "207RI0011X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Interventional Cardiology",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant, Medical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Deaconess IL Specialty Burns Ave",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "St. Louis Cardiovascular",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sparta, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 26, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.