DEACONESS IL SPECIALTY 4117 WATER TOWER
NPI 1003523374
Family Medicine in Mount Vernon, IL

Q: What is Deaconess Illinois Specialty Clinic, Inc.'s specialty?

The primary specialty registered for this NPI is Family Medicine with taxonomy code 207Q00000X.

Active since November 04, 2022CLIA 14D0436229 · Waiver

4117 S WATER TOWER PL STE C, MOUNT VERNON, IL 62864(618) 242-0672(618) 242-0862 Get Directions Write a Review

NPPES record last updated: January 26, 2023. Verified against the NPPES registry weekly; last sync: August 09, 2026.

Record update history: Jan 26, 2023, Dec 2, 2022, Nov 9, 2022 and 1 more (4 updates tracked since 2022).

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About Deaconess Il Specialty 4117 Water Tower NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

DEACONESS IL SPECIALTY 4117 WATER TOWER (NPI 1003523374) is a healthcare organization registered as a family medicine in Mount Vernon, Illinois and active in the NPI registry since November 2022. The organization holds a CLIA Waiver certificate valid through November 8, 2027 and lists Kyle Dillman, Secretary Treasurer, as its authorized official.

NPPES Registry Identity

NPI1003523374

Entity TypeOrganization

Primary Taxonomy207Q00000X

Legal Business NameDEACONESS ILLINOIS SPECIALTY CLINIC, INC.

Location Address4117 S WATER TOWER PL STE CMount Vernon, IL 62864-6567

Mailing AddressPo Box 34266Belfast, ME 04915-0620 · (812) 450-6815 · Fax (812) 450-6822

Phone(618) 242-0672

Fax(618) 242-0862

Organization SubpartNo

Authorized OfficialKyle DillmanSecretary Treasurer · (812) 450-7399

Enumeration DateNovember 4, 2022

Last NPPES UpdateJanuary 26, 20234 updates tracked since enumeration

NPPES CertifiedJanuary 26, 2023

✔ NPI 1003523374 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses 3

★ Primary SpecialtyFamily MedicineAllopathic & Osteopathic Physicians

Taxonomy Code207Q00000X

Definition

Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity.

Also ListedOtolaryngologyTaxonomy 207Y00000X

Also ListedAudiologistTaxonomy 231H00000X

4117 S WATER TOWER PL STE C, Mount Vernon, IL 62864

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Other Names 1

Doing Business AsDeaconess Il Specialty 4117 Water Tower

Group Practice 1

Group TaxonomyThis provider is a business group of one or more individual practitioners, who practice with different areas of specialization.193200000X MULTI-SPECIALTY GROUP

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 14D0436229

Deaconess Illinois Specialty Clinic Deaconess Illinois Specialty Clinic Inc · Mount Vernon, IL

Active · expires Nov 8, 2027

CLIA Number14D0436229

Laboratory TypePhysician Office

Certificate Effective DateNovember 9, 2025

Certificate Expiration DateNovember 8, 2027

Laboratory DirectorGary M. Reagan

Laboratory Phone(618) 244-6710

Laboratory LocationDeaconess Illinois Specialty Clinic Deaconess Illinois Specialty Clinic Inc209 Crossroads Place-Suite 150, Mount Vernon, IL 62864

CLIA data matches this NPI record on: Name

This certificate is issued to a laboratory to perform only waived tests.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Deaconess Illinois Specialty Clinic, Inc.'s NPI number?

The NPI number for Deaconess Illinois Specialty Clinic, Inc. is 1003523374. It was assigned to this organization in the NPPES registry on November 4, 2022. The provider is doing business as Deaconess Il Specialty 4117 Water Tower.

Where is Deaconess Illinois Specialty Clinic, Inc. located?

Deaconess Illinois Specialty Clinic, Inc. is located at 4117 S Water Tower Pl Ste C, Mount Vernon, IL 62864. The listed phone number is (618) 242-0672.

What is Deaconess Illinois Specialty Clinic, Inc.'s specialty?

The primary specialty registered for this NPI is Family Medicine with taxonomy code 207Q00000X.

Does Deaconess Illinois Specialty Clinic, Inc. hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 14D0436229) is associated with this NPI, valid through November 8, 2027. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Deaconess Illinois Specialty Clinic, Inc. was last updated on January 26, 2023. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 3 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.