Basic Information
| Provider Information | |||||||||
| NPI: | 1558316638 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAMARITAN FAMILY CARE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAMARITAN HOSPITALIST GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 PHILADELPHIA DR | ||||||||
| Address2: | STE 441 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454061840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377342230 | ||||||||
| FaxNumber: | 9375674186 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 PHILADELPHIA DR | ||||||||
| Address2: | STE 441 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454061840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377342230 | ||||||||
| FaxNumber: | 9375674186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 11/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | PRUNIER | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9372088213 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAMARITAN FAMILY CARE INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 2602133 | 05 | OH | MEDICAID |