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Recently Updated NPI Information — some details in this NPI profile have been updated in the NPI registry within the last 60 days.

DEACONESS ILLINOIS CLINIC, INC
NPI 1063104206
Family Medicine in Marion, IL

Active since May 25, 2023CLIA 14D2324652 · Waiver
3411 PROFESSIONAL PARK DR, MARION, IL 62959(618) 969-8630(618) 969-8639 Get Directions Write a Review

NPPES record last updated: July 15, 2026. Verified against the NPPES registry weekly; last sync: August 16, 2026.

Record update history: Jul 15, 2026, May 25, 2023 (2 updates tracked since 2023).

About Deaconess Illinois Clinic, Inc NPPES

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

DEACONESS ILLINOIS CLINIC, INC (NPI 1063104206) is a healthcare organization registered as a family medicine in Marion, Illinois and active in the NPI registry since May 2023. The organization holds a CLIA Waiver certificate valid through May 28, 2027 and lists Kyle Dillman, Secretary, as its authorized official.

NPPES Registry Identity

NPI1063104206
Entity TypeOrganization
Primary Taxonomy207Q00000X
Legal Business NameDEACONESS ILLINOIS CLINIC, INC
Location Address3411 PROFESSIONAL PARK DRMarion, IL 62959-6394
Mailing AddressPo Box 632330Cincinnati, OH 45263-2330 · (812) 450-6815 · Fax (812) 450-6822
Phone(618) 969-8630
Fax(618) 969-8639
Organization SubpartNo
Authorized OfficialKyle DillmanSecretary · (812) 450-7399
Enumeration DateMay 25, 2023
Last NPPES UpdateJuly 15, 20262 updates tracked since enumeration
NPPES CertifiedJuly 15, 2026
✔ NPI 1063104206 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses 4

★ 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 ListedPediatricsTaxonomy 208000000X
Also ListedPhysician AssistantTaxonomy 363A00000X
Also ListedNurse PractitionerTaxonomy 363L00000X
3411 PROFESSIONAL PARK DR, Marion, IL 62959
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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 2

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 14D2324652

Deaconess Il Clinic · Carterville, IL
Active · expires May 28, 2027
CLIA Number14D2324652
Laboratory TypePhysician Office
Certificate Effective DateMay 29, 2025
Certificate Expiration DateMay 28, 2027
Laboratory DirectorJodi Fox
Laboratory Phone(618) 969-8630
Laboratory LocationDeaconess Il Clinic700 Logan College Dr - J Building, Carterville, IL 62918
CLIA data matches this NPI record on: Phone
This certificate is issued to a laboratory to perform only waived tests.

Certificate of Waiver 14D2190844

Deaconess Illinois Clinic · Marion, IL
Expired · Aug 18, 2026
CLIA Number14D2190844
Laboratory TypePhysician Office
Certificate Effective DateAugust 19, 2024
Certificate Expiration DateAugust 18, 2026
Laboratory DirectorJodi Bryant
Laboratory Phone(618) 969-8630
Laboratory LocationDeaconess Illinois Clinic3411 Professional Park Dr, Marion, IL 62959
CLIA data matches this NPI record on: Address Name Phone
This certificate is issued to a laboratory to perform only waived tests.

Other Providers at the Same Location NPPES 7

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

LINDSEY SOLLERS
Nurse Practitioner
3411 PROFESSIONAL PARK DR
MARION, IL 62959
Williamson County (618) 997-2161
ROBIN ANN DAILEY
Nurse Practitioner
3411 PROFESSIONAL PARK DR
MARION, IL 62959
Williamson County (618) 997-2161
DR. JODI L FOX M.D.
Family Medicine
3411 PROFESSIONAL PARK DR
MARION, IL 62959
Williamson County (618) 997-2161
SOUTHERN ILLINOIS MEDICAL CARE ASSOCIATES LLC
Family Medicine
3411 PROFESSIONAL PARK DR
MARION, IL 62959
Williamson County (618) 997-2161
KALINDA JO SHAW
Nurse Practitioner
3411 PROFESSIONAL PARK DR
MARION, IL 62959
Williamson County (618) 969-8630
JAYNA LYNNE COWSERT PA-C
Physician Assistant
3411 PROFESSIONAL PARK DR
MARION, IL 62959
Williamson County (618) 997-2161
DIETRA LEIGH ANGELLY FNP-C
Nurse Practitioner
3411 PROFESSIONAL PARK DR
MARION, IL 62959
Williamson County (618) 969-8630

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 Clinic, Inc's NPI number?

The NPI number for Deaconess Illinois Clinic, Inc is 1063104206. It was assigned to this organization in the NPPES registry on May 25, 2023.

Where is Deaconess Illinois Clinic, Inc located?

Deaconess Illinois Clinic, Inc is located at 3411 Professional Park Dr, Marion, IL 62959. The listed phone number is (618) 969-8630.

What is Deaconess Illinois Clinic, Inc's specialty?

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

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

Yes. A Certificate of Waiver (number 14D2324652) is associated with this NPI, valid through May 28, 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 Clinic, Inc was last updated on July 15, 2026. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 34 days 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.