Basic Information
Provider Information | |||||||||
NPI: | 1225020605 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GOOD SAMARITAN HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GOOD SAMARITAN HOSPITAL INPATIENT REHAB | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 520 S 7TH ST | ||||||||
Address2: |   | ||||||||
City: | VINCENNES | ||||||||
State: | IN | ||||||||
PostalCode: | 475911038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8128825220 | ||||||||
FaxNumber: | 8128853917 | ||||||||
Practice Location | |||||||||
Address1: | 520 S 7TH ST | ||||||||
Address2: |   | ||||||||
City: | VINCENNES | ||||||||
State: | IN | ||||||||
PostalCode: | 475911038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8128825220 | ||||||||
FaxNumber: | 8128853917 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2005 | ||||||||
LastUpdateDate: | 11/26/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCLIN | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8128853193 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GOOD SAMARITAN HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 050050381 | IN | Y |   | Hospital Units | Rehabilitation Unit |   |
ID Information
ID | Type | State | Issuer | Description | 100270130C | 05 | IN |   | MEDICAID |