14D2313075 CLIA NUMBER - DEACONESS IL SPECIALTY CLINIC

Laboratory Demographics

  • CLIA Code: 14D2313075
  • Facility Name: DEACONESS IL SPECIALTY CLINIC
  • Facility Address: 209 CROSSROADS PLACE - STE 100
    MOUNT VERNON, IL
    ZIP 62864
  • Facility Phone: 618 241-9071
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: SRINIVAS ERRAGOLLA
  • NPI Number: 1114644747
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 14D2313075
LAB Type Physician Office
Facility Name DEACONESS IL SPECIALTY CLINIC
Street 209 CROSSROADS PLACE - STE 100
City MOUNT VERNON
State IL
ZIP 62864
Phone 618 241-9071
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 10/24/2024
Certificate Expiration Date 10/23/2026
Facility Type Physician Office
Lab Director SRINIVAS ERRAGOLLA

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This page was last updated on: 9/29/2025