Basic Information
| Provider Information | |||||||||
| NPI: | 1679597108 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEGACY GOOD SAMARITAN HOSPITAL AND MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEGACY GOOD SAMARITAN PROVIDERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3808 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 NW 23RD AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972102906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034137074 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 02/27/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CFO | ||||||||
| AuthorizedOfficialTelephone: | 5034155145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LEGACY GOOD SAMARITAN HOSPITAL AND MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 007002000 | 01 | OR | REGENCE BLUE CROSS | OTHER | 226827 | 05 | OR | MEDICAID | 1016129 | 05 | WA | MEDICAID | 135199 | 05 | OR | MEDICAID | CK6664 | 01 | OR | MEDICARE RAILROAD | OTHER | 002868000 | 01 | OR | REGENCE BLUE CROSS | OTHER |