Basic Information
Provider Information | |||||||||
NPI: | 1245993443 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GOOD SAMARITAN HOSPITAL PHYSICIAN SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1160 E SAINT CLAIR ST | ||||||||
Address2: |   | ||||||||
City: | VINCENNES | ||||||||
State: | IN | ||||||||
PostalCode: | 475914853 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8128853106 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 406 N 1ST ST STE B | ||||||||
Address2: |   | ||||||||
City: | VINCENNES | ||||||||
State: | IN | ||||||||
PostalCode: | 475911358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8128856950 | ||||||||
FaxNumber: | 8128856951 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/15/2021 | ||||||||
LastUpdateDate: | 10/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BILSKIE | ||||||||
AuthorizedOfficialFirstName: | BRIDGETT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 8128858763 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GOOD SAMARITAN HOSPITAL PHYSICIAN SERVICES, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.