Basic Information
| Provider Information | |||||||||
| NPI: | 1194884312 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD SAMARITAN HOSPITAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313763000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 929 SUNRISE HWY | ||||||||
| Address2: | |||||||||
| City: | BAY SHORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117065907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312248510 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 06/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | ALLISON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6313764003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 03000328 | 05 | NY | MEDICAID | 005308 | 01 | NY | BLUE CROSS | OTHER |