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DEACONESS ILLINOIS CLINIC, INC
NPI 1063128544
Family Medicine in Mount Vernon, IL

Active since January 27, 2023CLIA 14D2277676 · Waiver
4105 N WATER TOWER PL, MOUNT VERNON, IL 62864(812) 450-6815 Get Directions Write a Review

NPPES record last updated: January 27, 2023. Verified against the NPPES registry weekly; last sync: August 16, 2026.

About Deaconess Illinois Clinic, Inc NPPES

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

DEACONESS ILLINOIS CLINIC, INC (NPI 1063128544), doing business as Deaconess Il Clinic 4105 N Water Tower, is a healthcare organization registered as a family medicine in Mount Vernon, Illinois and active in the NPI registry since January 2023. The organization holds a CLIA Waiver certificate valid through March 1, 2027 and lists Kyle Dillman, Secretary, as its authorized official.

NPPES Registry Identity

NPI1063128544
Entity TypeOrganization
Primary Taxonomy207Q00000X
Legal Business NameDEACONESS ILLINOIS CLINIC, INC
Location Address4105 N WATER TOWER PLMount Vernon, IL 62864-6296
Mailing AddressPo Box 34156Belfast, ME 04915-0619 · (812) 450-6815 · Fax (812) 450-6822
Phone(812) 450-6815
Organization SubpartNo
Authorized OfficialKyle DillmanSecretary · (812) 450-7399
Enumeration DateJanuary 27, 2023
NPPES CertifiedJanuary 20, 2023
✔ NPI 1063128544 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ 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.
4105 N WATER TOWER PL, Mount Vernon, IL 62864
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Other Names 1

Doing Business AsDeaconess Il Clinic 4105 N Water Tower

Group Practice 1

Group TaxonomyThis provdier is a business group of one or more individual practitioners, all of who practice with the same area of specialization.193400000X SINGLE 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 14D2277676

Deaconess Illinois Clinic Deaconess Illinois Clinic, Inc · Mount Vernon, IL
Active · expires Mar 1, 2027
CLIA Number14D2277676
Laboratory TypePhysician Office
Certificate Effective DateMarch 2, 2025
Certificate Expiration DateMarch 1, 2027
Laboratory DirectorDennon W. Davis
Laboratory Phone(618) 244-9495
Laboratory LocationDeaconess Illinois Clinic Deaconess Illinois Clinic, Inc4105 N Water Tower Place, Mount Vernon, IL 62864
CLIA data matches this NPI record on: Address Name
This certificate is issued to a laboratory to perform only waived tests.

Other Providers at the Same Location NPPES 3

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

JASON DWIGHT BERNARD
Nurse Practitioner
4105 N WATER TOWER PL
MOUNT VERNON, IL 62864
Jefferson County (618) 244-9495
DENNON W DAVIS M.D.
Family Medicine
4105 N WATER TOWER PL
MOUNT VERNON, IL 62864
Jefferson County (618) 244-9495
JULIE A LAMPLEY-DOUGLASS PA-C
Physician Assistant (Medical)
4105 N WATER TOWER PL
MOUNT VERNON, IL 62864
Jefferson County (618) 246-2910

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 1063128544. It was assigned to this organization in the NPPES registry on January 27, 2023. The provider is doing business as Deaconess IL Clinic 4105 N Water Tower.

Where is Deaconess Illinois Clinic, Inc located?

Deaconess Illinois Clinic, Inc is located at 4105 N Water Tower Pl, Mount Vernon, IL 62864. The listed phone number is (812) 450-6815.

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 14D2277676) is associated with this NPI, valid through March 1, 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 January 27, 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.