Basic Information
| Provider Information | |||||||||
| NPI: | 1417956152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOOD SAMARITAN HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAMARITAN CENTER - WILLOWS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 515 BAYOU ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128866800 | ||||||||
| FaxNumber: | 8128866809 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 WILLOW ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475914277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128852720 | ||||||||
| FaxNumber: | 8128852723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MANNING | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP BEHAVIORAL HEALTH/SPEC PROJECTS | ||||||||
| AuthorizedOfficialTelephone: | 8128866800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GOOD SAMARITAN HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 4030 | IN | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YS0200X | 4030 | IN | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | School | 103TC0700X | 4030 | IN | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | 4030 | IN | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X | 4030 | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 251S00000X | 4030CMHC | IN | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 000000574020 | 01 | IN | ATHEM PIN FOR THIS LOCATION | OTHER | 100270140G | 05 | IN | MEDICAID | 100270140D | 05 | IN | MEDICAID | 165526 | 01 | IN | MHN | OTHER | 192453000 | 01 | IN | MAGELLAN | OTHER | 301936 | 01 | IN | VALUE OPTIONS FACILITY | OTHER | 200898460A | 05 | IN | MEDICAID |