Basic Information
Provider Information | |||||||||
NPI: | 1952579195 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GOOD SAMARITAN HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAMARITAN CENTER - TRANSPORTATION | ||||||||
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: | 515 BAYOU ST | ||||||||
Address2: |   | ||||||||
City: | VINCENNES | ||||||||
State: | IN | ||||||||
PostalCode: | 475911034 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8128866800 | ||||||||
FaxNumber: | 8128866809 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2008 | ||||||||
LastUpdateDate: | 06/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MANNING | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8128852709 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GOOD SAMARITAN HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 4030CMHC | IN | N |   | Agencies | Community/Behavioral Health |   | 347C00000X |   | IN | Y |   | Transportation Services | Private Vehicle |   |
ID Information
ID | Type | State | Issuer | Description | 200089590A | 05 | IN |   | MEDICAID |