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Deaconess Memorial Medical Center Inc

Organization Active NPI Family Medicine Physician · Petersburg, IN

NPI 1689770083 · NPPES record last updated Mar 16, 2026

Key facts

NPI
1689770083
Entity type
Organization (NPI type 2)
Primary specialty
Family Medicine Physician 207Q00000X
Legal business name
DEACONESS MEMORIAL MEDICAL CENTER INC
Practice address
1003 E Illinois St
Petersburg, IN 47567
Phone
(812) 354-3458
Fax
(812) 354-3459
NPI assigned
Sep 15, 2006
Organization subpart
Yes
Parent organization (as reported)
DEACONESS MEMORIAL MEDICAL CENTER INC

Authorized official

Name
Keith Miller
Title
Cao & Indiana Region President
Phone
(812) 996-0507

Owners & managing parties with NPI records 3

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

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs on the same Medicare enrollment 36

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

View all 36

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Facilities with the same owner 28

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 28

Practitioners 144

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 144

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in IN

Rural health clinic certification: CCN 153872

Legal name
DEACONESS MEMORIAL MEDICAL CENTER INC
Doing business as
PETERSBURG FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 5, 2004
Last certification
Oct 23, 2024
Ownership / control type
2B
Organization structure
Corporation · Non-profit
Incorporated
Jun 13, 1950 in IN
Enrollment address
1003 E Illinois Street
Petersburg, IN 47567-8068

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 Director Jan 1, 2013
Kristi M Nord
Individual 		Corporate Director Jan 1, 2024
Renee Cunningham
Individual 		Corporate Director Jan 1, 2012
Sohail Qadir
Individual 		Corporate Director
Board Member		 Jul 1, 2015
Shannon Ebenkamp
Individual 		W-2 Managing Employee
Director of Finance		 Oct 8, 2024
James a Huebner
Individual 		Corporate Director
Board 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%
Operational/Managerial Control Feb 1, 2024
Lynn C Lingafelter
Individual 		Corporate Director Feb 1, 2024
Christian Blome
Individual 		Corporate Director Feb 1, 2024
Shawn W McCoy
Individual 		Corporate Director Feb 1, 2024
Keith Miller
Individual 		Corporate Officer
Cao & Indiana Region President		 Oct 8, 2024
W-2 Managing Employee
Ad;		 Oct 8, 2024
James Porter
Individual 		Corporate Director Feb 1, 2024
Donna Balka
Individual 		Corporate Director
Board Member		 May 1, 2021
Nicholas a Werne
Individual 		Corporate Director Aug 5, 2022

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Mission Behavioral Health Hospital
Huntingburg, IN · CCN 154072		 Hospital 5% Or Greater Direct Ownership Interest (50%) Apr 5, 2024
Dale Family Medicine
Dale, IN · CCN 153859		 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jun 2, 2000

Medicare enrollment records

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…
O20130625000681 IN Part a Provider - Rural Health Clinic 4587578042 Practice locations: Petersburg, IN

National Provider Directory

Part of
Little Company Hosp in Inc

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician
Group: 193200000X MULTI-SPECIALTY GROUP		 207Q00000X Yes
Rural Health Clinic/Center 261QR1300X
Physician Assistant
Group: 193200000X MULTI-SPECIALTY GROUP		 363A00000X
Nurse Practitioner
Group: 193200000X MULTI-SPECIALTY GROUP		 363L00000X

Addresses

Primary practice location

1003 E Illinois St
Petersburg, IN 47567

Mailing address

800 W 9TH St
Jasper, IN 47546-2514
Phone (812) 996-8478

Other identifiers

IdentifierTypeStateIssuer
CB3118OtherINMEDICARE RAILROAD
200048850KMedicaidIN

Other names

  • PETERSBURG FAMILY MEDICINE Doing business as

Other providers in Petersburg, IN

All providers in Petersburg, IN · Family Medicine Physician in Indiana

Sources for this page

Verify at the official NPI Registry.