Basic Information
| Provider Information | |||||||||
| NPI: | 1679728588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD SAMARITIAN PHYSICIAN SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLSPAN GENERAL SURGERY - LEBANON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 300 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170420300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172707780 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 735 NORMAN DR | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170427559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172707908 | ||||||||
| FaxNumber: | 7172721734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2008 | ||||||||
| LastUpdateDate: | 10/05/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOGER | ||||||||
| AuthorizedOfficialFirstName: | JODY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7172707780 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001864024 | 05 | PA | MEDICAID |