Basic Information
| Provider Information | |||||||||
| NPI: | 1295114767 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD SAMARITAN HOSPITAL CORVALLIS | ||||||||
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| OtherOrganizationName: | SAMARITAN NEUROMUSCULAR MEDICINE RESIDENT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1189 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973391189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417686768 | ||||||||
| FaxNumber: | 5417689771 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 NW SAMARITAN DR | ||||||||
| Address2: | SUITE 203A | ||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973304714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417684810 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2015 | ||||||||
| LastUpdateDate: | 12/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | TRIEBES | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5418124102 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/23/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | 14-1074 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
No ID Information.