Basic Information
| Provider Information | |||||||||
| NPI: | 1235182668 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAMARITAN FAMILY CARE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HUBER HEIGHTS SAMARITAN PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B3 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913100 | ||||||||
| FaxNumber: | 9372338389 | ||||||||
| Practice Location | |||||||||
| Address1: | 6251 GOOD SAMARITAN WAY | ||||||||
| Address2: | SUITE 210C | ||||||||
| City: | HUBER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454241051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372333910 | ||||||||
| FaxNumber: | 9372338389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRUNIER | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9372088213 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAMARITAN FAMILY CARE INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0230502 | 05 | OH | MEDICAID |