Basic Information
| Provider Information | |||||||||
| NPI: | 1770575201 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOOD SAMARITAN HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GOOD SAMARITAN HOSPITAL MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1160 E SAINT CLAIR ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475914853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128825220 | ||||||||
| FaxNumber: | 8128853913 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 S 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128825220 | ||||||||
| FaxNumber: | 8128853917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/14/2008 | ||||||||
| NPIReactivationDate: | 06/17/2008 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ASH | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | NICHOLE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 8128853106 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GOOD SAMARITAN HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 080050381 | IN | N | Hospitals | General Acute Care Hospital | 273R00000X | 050050381 | IN | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 100270130D | 05 | IN | MEDICAID |