Basic Information
Provider Information
NPI: 1346514015
EntityType: 2
ReplacementNPI:  
OrganizationName: GOOD SAMARITAN HOSPITAL CORVALLIS
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: SAMARITAN FAMILY MEDICINE RESIDENT CLINIC
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 1189
Address2:  
City: CORVALLIS
State: OR
PostalCode: 973391189
CountryCode: US
TelephoneNumber: 5417686768
FaxNumber: 5417689771
Practice Location
Address1: 3517 NW SAMARITAN DRIVE SUITE 201
Address2:  
City: CORVALLIS
State: OR
PostalCode: 973303769
CountryCode: US
TelephoneNumber: 5417685142
FaxNumber: 5417685355
Other Information
ProviderEnumerationDate: 02/28/2012
LastUpdateDate: 03/16/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: PAPE
AuthorizedOfficialFirstName: BECKY
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: COO
AuthorizedOfficialTelephone: 5417685009
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 
207Q00000X14-1074-5ORY193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
50065219705OR MEDICAID


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