NPIMap

Organization Active NPI

Deaconess Illinois Clinic, Inc

Doing business as Deaconess IL Clinic Eleven S

  • Family Medicine Physician
  • Columbia, IL
National Provider Identifier
1962128256
Registry record updated Jan 26, 2023
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 IL Clinic Eleven S
Family Practice Associates
Practice address
1000 Eleven S Ste 2E
Columbia, IL 62236-1079
Phone
(618) 281-2773
Fax
(618) 281-0245
NPI assigned
Oct 18, 2022
Last updated
Jan 26, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 26, 2023

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
Physician Assistant 363A00000X NU
Nurse Practitioner 363L00000X NU
Family Medicine Physician 207Q00000X NU Primary

Addresses

Primary practice location

1000 Eleven S Ste 2E
Columbia, IL 62236-1079

Mailing address

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

Other names 2

  • Deaconess IL Clinic Eleven S Doing business as
  • Family Practice Associates Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230220002667 IL Part B Supplier - Clinic/Group Practice 5092187021 Receives reassigned benefits from 33 practitioners
10 other NPIs on this enrollment
Practice locations: Marion, IL; Waterloo, IL; Mount Vernon, IL; Harrisburg, IL; Columbia, IL; Carterville, IL; Benton, IL

Other NPIs on the same Medicare enrollment 10

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

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 35

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.

View all 35

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": "1674691200000",
    "number": "1962128256",
    "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": "1000 ELEVEN S STE 2E",
            "city": "COLUMBIA",
            "state": "IL",
            "postal_code": "622361079",
            "telephone_number": "618-281-2773",
            "fax_number": "618-281-0245"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEACONESS ILLINOIS CLINIC, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-10-18",
        "last_updated": "2023-01-26",
        "certification_date": "2023-01-26",
        "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": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Deaconess IL Clinic Eleven S",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Family Practice Associates",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Columbia, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 26, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.