Basic Information
| Provider Information | |||||||||
| NPI: | 1790904225 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOOD SAMARITAN HOSPITAL CORVALLIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOOD SAMARITAN REGIONAL MEDICAL CENTER-INPATIENT MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1189 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973391189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417685144 | ||||||||
| FaxNumber: | 5417685201 | ||||||||
| Practice Location | |||||||||
| Address1: | 3509 NW SAMARITAN DRIVE SUITE 100 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973303766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417685144 | ||||||||
| FaxNumber: | 5417685201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 12/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | PAPE | ||||||||
| AuthorizedOfficialFirstName: | BECKY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5417685009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 14-1074 | OR | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 72652 | 05 | OR | MEDICAID |