Basic Information
Provider Information
NPI: 1043218613
EntityType: 2
ReplacementNPI:  
OrganizationName: GOOD SAMARITAN HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: SAMARITAN CENTER - WASHINGTON
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 515 BAYOU ST
Address2:  
City: VINCENNES
State: IN
PostalCode: 475911034
CountryCode: US
TelephoneNumber: 8128866800
FaxNumber: 8128866809
Practice Location
Address1: 2007 STATE ST
Address2:  
City: WASHINGTON
State: IN
PostalCode: 475018505
CountryCode: US
TelephoneNumber: 8122541558
FaxNumber: 8122548308
Other Information
ProviderEnumerationDate: 07/08/2005
LastUpdateDate: 04/24/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MANNING
AuthorizedOfficialFirstName: JOHN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: VP BEHAVIORAL HEALTH/SPEC PROJECTS
AuthorizedOfficialTelephone: 8128866800
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: GOOD SAMARITAN HOSPITAL
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X4030INN193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersCounselor 
101YA0400X4030INN193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
104100000X4030INN193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersSocial Worker 
1041C0700X4030INN193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersSocial WorkerClinical
2084P0800X4030INN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
2084P0804X4030INN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
363LF0000X4030INN193200000X MULTI-SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
251S00000X4030CMHCINY AgenciesCommunity/Behavioral Health 

ID Information
IDTypeStateIssuerDescription
100270140E05IN MEDICAID
16552601INMHN GROUPOTHER
00000057403101INATHEM PIN FOR THIS LOCATIONOTHER
100270140G05IN MEDICAID
30193601INVALUE OPTIONSOTHER
15100800001INMAGELLANOTHER


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