DEACONESS IL SPECIALTY EXPRESS BROADWAY ST
NPI 1497462964
Nurse Practitioner in Mount Vernon, IL
About Deaconess Il Specialty Express Broadway St NPPES
Official registry information on file with the National Plan and Provider Enumeration System.
DEACONESS IL SPECIALTY EXPRESS BROADWAY ST (NPI 1497462964) is a healthcare organization registered as a nurse practitioner in Mount Vernon, Illinois and active in the NPI registry since November 2022. The organization lists Kyle Dillman, Secretary Treasurer, as its authorized official.
NPPES Registry Identity
Specialties & Licenses 2
Other Names 1
Group Practice 1
Medicare Participation & PECOS CMS
Medicare enrollment and the clinicians who bill Medicare through this organization, from CMS.
Medicare Enrollment Status
Enrolled in Medicare (PECOS)
Deaconess Il Specialty Express Broadway St is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).
Clinicians Billing Medicare Through This Organization
227Medicare enrollment records show 227 clinicians reassign Medicare billing to Deaconess Il Specialty Express Broadway St, which bills Medicare for the services they deliver. Of these, 2 practice at this address and 22 within 10 miles. Listed here are the 20 practicing nearest to this location.
Clinicians by Medicare Specialty 29
Nearest to this location (20)
See all 227Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
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 14D2270655
Deaconess Illinois Specialty Clinic Express · Mount Vernon, ILFrequently 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 1497462964. It was assigned to this organization in the NPPES registry on November 3, 2022. The provider is doing business as Deaconess Il Specialty Express Broadway St.
Where is Deaconess Illinois Specialty Clinic, Inc. located?
Deaconess Illinois Specialty Clinic, Inc. is located at 3111 Broadway St, Mount Vernon, IL 62864. The listed phone number is (618) 241-0300.
What is Deaconess Illinois Specialty Clinic, Inc.'s specialty?
The primary specialty registered for this NPI is Nurse Practitioner with taxonomy code 363L00000X.
Is Deaconess Illinois Specialty Clinic, Inc. enrolled in Medicare?
Yes. Deaconess Illinois Specialty Clinic, Inc. is registered in the Medicare PECOS enrollment system.
How many clinicians bill Medicare through Deaconess Illinois Specialty Clinic, Inc.?
According to the CMS Revalidation Reassignment List (October 2026 release), 227 clinicians in 29 Medicare specialties reassign their Medicare billing to Deaconess Illinois Specialty Clinic, Inc.. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. The largest specialties are Nurse Practitioner (56), Family Practice (26) and Internal Medicine (24). Of these, 2 practice at this address and 22 within 10 miles. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
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.
# Deaconess Il Specialty Express Broadway St · NPI 1497462964
Nurse Practitioner organization in Mount Vernon, Illinois. Organization record, active in the CMS NPPES registry since November 3, 2022.
## Identity
- **NPI:** 1497462964 (Entity type: Organization)
- **Enumerated:** November 3, 2022
- **Primary specialty:** Nurse Practitioner · taxonomy 363L00000X
- **Legal business name:** Deaconess Illinois Specialty Clinic, Inc.
- **Organization subpart:** No
- **Authorized official:** Kyle Dillman, SECRETARY TREASURER
## Practice location
- **Address:** 3111 BROADWAY ST, Mount Vernon, IL 62864-2338
- **Phone:** (618) 241-0300 · **Fax:** (618) 241-0302
## Medicare
- **Medicare:** Enrolled in Medicare (PECOS)
- **Clinicians billing through this organization:** 227 clinicians in 29 Medicare specialties reassign Medicare billing to this organization (form CMS-855R); largest: Nurse Practitioner (56), Family Practice (26), Internal Medicine (24); 2 practice at this address and 22 within 10 miles; [full list](https://npiprofile.com/npi/1497462964/clinicians) · CMS Revalidation Reassignment List, October 2026 release
## Record status
- **NPPES last updated:** January 26, 2023
- **CLIA laboratory certificates:** 1 on file
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Source: [NPI Profile](https://npiprofile.com/npi/1497462964) · Data from the CMS NPPES public registry.