Provider Demographics
NPI:1790863835
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:812-996-0507
Mailing Address - Street 1:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-1028
Mailing Address - Country:US
Mailing Address - Phone:812-481-8483
Mailing Address - Fax:812-481-8497
Practice Address - Street 1:721 W 13TH ST
Practice Address - Street 2:SUITE 122
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1855
Practice Address - Country:US
Practice Address - Phone:812-482-0626
Practice Address - Fax:812-482-0650
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEACONESS MEMORIAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-02
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCB1118OtherRAILROAD MEDICARE
IN200048850NMedicaid