Provider Demographics
NPI:1700966777
Name:DEACONESS MEMORIAL MEDICAL CENTER INC
Entity type:Organization
Organization Name:DEACONESS MEMORIAL MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAO & INDIANA REGION PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-969-0507
Mailing Address - Street 1:800 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-2514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:812-481-8497
Practice Address - Street 1:115 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FERDINAND
Practice Address - State:IN
Practice Address - Zip Code:47532-9534
Practice Address - Country:US
Practice Address - Phone:812-367-1906
Practice Address - Fax:812-367-2487
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEACONESS MEMORIAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-16
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200048850BMedicaid
INCB3118OtherRAILROAD MEDICARE