NPIMap

Organization Active NPI

Deaconess Clinic, Inc

  • Rural Health Clinic/Center
  • Dixon, KY
National Provider Identifier
1942924766
Registry record updated Apr 27, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
DEACONESS CLINIC, INC
Practice address
1355 US Highway 41a S
Dixon, KY 42409-9447
Phone
(270) 639-9101
NPI assigned
Sep 27, 2022
Last updated
Apr 27, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 27, 2023

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

Authorized official

Name
Cheryl Annette Wathen
Title
Cfo
Phone
(812) 450-3296

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU
Rural Health Clinic/Center 261QR1300X NU Primary
Nurse Practitioner 363L00000X NU
Family Nurse Practitioner 363LF0000X NU

Addresses

Primary practice location

1355 US Highway 41a S
Dixon, KY 42409-9447

Mailing address

PO Box 1510
Evansville, IN 47706-1510
Phone (812) 450-6815

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20081017000259 KY Part B Supplier - Clinic/Group Practice 3375610116 Receives reassigned benefits from 190 practitioners
28 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Sebree, KY; Philpot, KY; Owensboro, KY; Morganfield, KY; Madisonville, KY; Henderson, KY; Dixon, KY
O20221115003481 KY Part A Provider - Rural Health Clinic 3375610116 Practice locations: Dixon, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1942924766. Details of each certification follow.

Rural health clinic certification: CCN B03930

Legal name
DEACONESS CLINIC INC
Doing business as
DEACONESS CLINIC DIXON RHC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 8, 2023
Last certification
Sep 8, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 2008 in IN
Enrollment address
1355 US Highway 41a S
Dixon, KY 42409-9447

Other NPIs with the same Medicare PAC ID 9

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

Other NPIs on the same Medicare enrollment 28

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

View all 28

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
18D0326507Deaconess Clinic Dixon RHC1355 US Hwy 41 a South, Dixon, KY 42409Provider-performed microscopyMar 21, 2028

National Provider Directory

National Provider Directory
Tax ID family
Deaconess Clinic100 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 15

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 15

Ownership & related parties

All disclosed owners & managing parties 15

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Mia Souheil Hindi Individual Corporate DirectorBoard Member Oct 1, 2015
Garrett C Koon Individual Corporate DirectorBoard Member Oct 1, 2020
Ashley Lynn Richeson Individual Corporate DirectorBoard Member Oct 1, 2020
Deaconess Health System Inc Organization, Evansville, IN Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jul 1, 2008 100%
Snesha Modi Individual Corporate DirectorBoard Member Oct 1, 2020
William R Smith Individual Corporate DirectorBoard Member Oct 1, 2015
Jason F White Individual Corporate DirectorBoard Member Oct 1, 2022
Barry S Phillips Individual Corporate DirectorBoard Member Oct 1, 2015
Jamie L Mull Individual Corporate DirectorBoard Member Oct 1, 2021
Cheryl Wathen Individual Corporate OfficerCfo Oct 1, 2012
W-2 Managing EmployeeCfo Oct 1, 2012
Stephen T Titzer Individual Corporate DirectorBoard Member Oct 1, 2012
Shawn W McCoy Individual Corporate OfficerCeo Oct 1, 2017
W-2 Managing EmployeeCeo Oct 1, 2017
Chris E Chacko Individual Corporate DirectorBoard Member Oct 1, 2019
Gary J Keepes Individual Corporate DirectorBoard Member Oct 1, 2019
Dhruvin Mehta Individual Corporate DirectorBoard Member Oct 1, 2022

Owners & managing parties with NPI records 11

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

Facilities with the same owner 28

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

View all 28

Practitioners & affiliated clinicians

Practitioners 4

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": "1664236800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682553600000",
    "number": "1942924766",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1510",
            "city": "EVANSVILLE",
            "state": "IN",
            "postal_code": "477061510",
            "telephone_number": "812-450-6815"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1355 US HIGHWAY 41A S",
            "city": "DIXON",
            "state": "KY",
            "postal_code": "424099447",
            "telephone_number": "270-639-9101"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS CLINIC, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-09-27",
        "last_updated": "2023-04-27",
        "certification_date": "2023-04-27",
        "status": "A",
        "authorized_official_last_name": "WATHEN",
        "authorized_official_first_name": "CHERYL",
        "authorized_official_middle_name": "ANNETTE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "812-450-3296"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Dixon, KY

Sources for this page

Verify at the official NPI Registry.