NPIMap

Organization Active NPI

Deaconess Illinois Clinic, Inc

Doing business as Deaconess Illinois Clinic

  • Family Medicine Physician
  • Saint Louis, MO
National Provider Identifier
1659097947
Registry record updated Dec 2, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
DEACONESS ILLINOIS CLINIC, INC
Doing business as
Deaconess Illinois Clinic
Practice address
1028 S Kirkwood Rd
Saint Louis, MO 63122-7222
Phone
(314) 287-6184
Fax
(314) 394-2253
NPI assigned
Oct 18, 2022
Last updated
Dec 2, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 2, 2022

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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary
Interventional Cardiology Physician 207RI0011X NU
Nurse Practitioner 363L00000X NU

Addresses

Primary practice location

1028 S Kirkwood Rd
Saint Louis, MO 63122-7222

Mailing address

PO Box 34156
Belfast, ME 04915-0619
Phone (812) 450-6815

Other names 1

  • Deaconess Illinois Clinic Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Deaconess Illinois Clinic21 organizations share this tax ID, including this one

Other organizations with this tax ID 20

Organizations that report the same tax identification number in the National Provider Directory.

View all 20

NPI Registry JSON

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

{
    "created_epoch": "1666051200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1669939200000",
    "number": "1659097947",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 34156",
            "city": "BELFAST",
            "state": "ME",
            "postal_code": "049150619",
            "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": "1028 S KIRKWOOD RD",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631227222",
            "telephone_number": "314-287-6184",
            "fax_number": "314-394-2253"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS ILLINOIS CLINIC, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-10-18",
        "last_updated": "2022-12-02",
        "certification_date": "2022-12-02",
        "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": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207RI0011X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Interventional Cardiology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Deaconess Illinois Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Deaconess Illinois Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Saint Louis, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 2, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.