Basic Information
| Provider Information | |||||||||
| NPI: | 1336576875 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD SAMARITAN HOSPITAL PHYSICIAN SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOOD SAMARITAN HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 E SAINT CLAIR ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475914853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128853453 | ||||||||
| FaxNumber: | 8128858499 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 N 1ST STREET | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128824694 | ||||||||
| FaxNumber: | 8128820630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2013 | ||||||||
| LastUpdateDate: | 10/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8128853891 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GOOD SAMARITAN HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | IN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363LF0000X | IN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 100270150 | 05 | IN | MEDICAID |