Basic Information
| Provider Information | |||||||||
| NPI: | 1720161086 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAMARITAN FAMILY CARE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY MEDICINE OF VANDALIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 FALLS CREEK DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | VANDALIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453778600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374540317 | ||||||||
| FaxNumber: | 9374541668 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 FALLS CREEK DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | VANDALIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453778600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374540317 | ||||||||
| FaxNumber: | 9374541668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 11/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | PRUNIER | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDEN | ||||||||
| AuthorizedOfficialTelephone: | 9372088273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAMARITAN FAMILY CARE INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2552134 | 05 | OH | MEDICAID |