Basic Information
| Provider Information | |||||||||
| NPI: | 1164735957 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEWARD GOOD SAMARITAN MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOOD SAMARITAN MEDICAL CENTER PSYCHIATRIC UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 N PEARL ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023011794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084273000 | ||||||||
| FaxNumber: | 6175627241 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 N PEARL ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023011794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084273000 | ||||||||
| FaxNumber: | 6175627241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2010 | ||||||||
| LastUpdateDate: | 11/09/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RENNA | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6174194700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STEWARD HEALTH CARE SYSTEM LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 110086667B | 05 | MA | MEDICAID |