Basic Information
| Provider Information | |||||||||
| NPI: | 1538435466 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD SAMARITAN HOSPITAL CORVALLIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAMARITAN KIDNEY SPECIALISTS - CORVALLIS | ||||||||
| 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: | 3615 NW SAMARITAN DRIVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973303771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417686930 | ||||||||
| FaxNumber: | 5417686931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 03/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | PAPE | ||||||||
| AuthorizedOfficialFirstName: | BECKY | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5417685009 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 14-1074 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 500657712 | 05 | OR | MEDICAID |