Deaconess Illinois Specialty Clinic, Inc.
Organization Active NPI Interventional Cardiology Physician · Sparta, IL
NPI 1619684172 · NPPES record last updated Jan 26, 2023
Key facts
- NPI
- 1619684172
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Interventional Cardiology Physician 207RI0011X
- Legal business name
- DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
- Practice address
- 205 S Burns Ave
Sparta, IL 62286-1867 - Phone
- (618) 443-2858
- Fax
- (618) 939-4256
- 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 5
-
Heather Diane Alexander, FNP-BC
-
Eric Sean Graham, MD
-
Jeffrey M Lehman, MD
-
Kara Kimberly Roth, APN-DNP
-
Mark Kiplagat Rotich, M.D.
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 |
|---|---|---|---|---|
| Interventional Cardiology Physician |
207RI0011X | Yes | ||
| Physician Assistant |
363A00000X | |||
| Medical Physician Assistant |
363AM0700X | |||
| Nurse Practitioner |
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
- Deaconess IL Specialty Burns Ave
- St. Louis Cardiovascular
Other providers in Sparta, IL
- Kermit Cox
- Nancy Ann Davison
- Deaconess Illinois Clinic, Inc
- Deaconess Illinois Clinic, Inc
- Deaconess Illinois Specialty Clinic, Inc.
- Alisa D Dearmond
- Andra Marie Dehn
- Jennifer Adele Demsar
- Amanda Durr
- Ashley Suzanne Eggemeyer
All providers in Sparta, IL · Interventional Cardiology Physician 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.