Basic Information
| Provider Information | |||||||||
| NPI: | 1043250780 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD SAMARITAN MEDICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 ELDORADO BLVD | ||||||||
| Address2: | STE 6250 | ||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800213408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032720820 | ||||||||
| FaxNumber: | 3036896674 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 EXEMPLA CIR | ||||||||
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| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800263370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036894000 | ||||||||
| FaxNumber: | 3034674156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 04/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | ALDERFER | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | DEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3036895212 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207V00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208600000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 07179073 | 05 | CO | MEDICAID |