Basic Information
| Provider Information | |||||||||
| NPI: | 1740451038 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD SAMARITAN HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HEART OF AMERICA JOHNSON CLINIC -MADDOCK | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 S MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | RUGBY | ||||||||
| State: | ND | ||||||||
| PostalCode: | 583682118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017765261 | ||||||||
| FaxNumber: | 7017765448 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | MADDOCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 583487138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014382555 | ||||||||
| FaxNumber: | 7014382551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2008 | ||||||||
| LastUpdateDate: | 04/16/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHRISTENSON | ||||||||
| AuthorizedOfficialFirstName: | ERIK | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7017765261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1457113 | 05 | ND | MEDICAID |