# DEACONESS ILLINOIS CLINIC, INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Deaconess Illinois Clinic
- **Organization subpart:** No

## Provider details

- **NPI number:** 1659097947
- **Authorized official:** KYLE DILLMAN (SECRETARY / TREASURER)
- **Authorized official phone:** (812) 450-7399

## Contact information

- **Practice address:** 1028 S KIRKWOOD RD, SAINT LOUIS, MO 63122-7222
- **Practice address phone:** (314) 287-6184
- **Practice address fax:** (314) 394-2253
- **Mailing address:** PO BOX 34156, BELFAST, ME 04915-0619
- **Mailing address phone:** (812) 450-6815
- **Mailing address fax:** (812) 450-6822

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207RI0011X | Interventional Cardiology Physician | — | NULL | — |
| 207RI0011X | Interventional Cardiology Physician | — | — | — |
| 363L00000X | Nurse Practitioner | — | NULL | — |
| 363L00000X | Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 10/18/2022
- **Last updated:** 12/02/2022