NPIMap

Organization Active NPI

Deaconess Illinois Specialty Clinic, Inc.

Doing business as Deaconess Illinois Specialty Clinic Occupational Health Broadway

  • Occupational Health Nurse Practitioner
  • Mount Vernon, IL
National Provider Identifier
1679270763
Registry record updated Feb 9, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Occupational Health Nurse PractitionerTaxonomy code 363LX0106X
Legal business name
DEACONESS ILLINOIS SPECIALTY CLINIC, INC.
Doing business as
Deaconess Illinois Specialty Clinic Occupational Health Broadway
Practice address
3111 Broadway St
Mount Vernon, IL 62864-2338
Phone
(618) 241-0333
Fax
(618) 241-0334
NPI assigned
Feb 9, 2023
Last updated
Feb 9, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 9, 2023

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Occupational Health Nurse Practitioner 363LX0106X NU Primary

Addresses

Primary practice location

3111 Broadway St
Mount Vernon, IL 62864-2338

Mailing address

3111 Broadway St
Mount Vernon, IL 62864-2338
Phone (618) 241-0333

Other names 1

  • Deaconess Illinois Specialty Clinic Occupational Health Broadway Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Deaconess Illinois Specialty Clinic Inc19 organizations share this tax ID, including this one

Other organizations with this tax ID 18

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

View all 18

NPI Registry JSON

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

{
    "created_epoch": "1675900800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1675900800000",
    "number": "1679270763",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3111 BROADWAY ST",
            "city": "MOUNT VERNON",
            "state": "IL",
            "postal_code": "628642338",
            "telephone_number": "618-241-0333",
            "fax_number": "618-241-0334"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3111 BROADWAY ST",
            "city": "MOUNT VERNON",
            "state": "IL",
            "postal_code": "628642338",
            "telephone_number": "618-241-0333",
            "fax_number": "618-241-0334"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS ILLINOIS SPECIALTY CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-02-09",
        "last_updated": "2023-02-09",
        "certification_date": "2023-02-09",
        "status": "A",
        "authorized_official_last_name": "DILLMAN",
        "authorized_official_first_name": "KYLE",
        "authorized_official_title_or_position": "SECRETARY",
        "authorized_official_telephone_number": "812-450-7399"
    },
    "taxonomies": [
        {
            "code": "363LX0106X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Occupational Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Deaconess Illinois Specialty Clinic Occupational Health Broadway",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mount Vernon, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 9, 2023; 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.