Basic Information
| Provider Information | |||||||||
| NPI: | 1861752073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOOD SAMARITAN PHYSICIAN SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GOOD SAMARITAN PHYSICIAN SERVICES FAMILY SUPPORT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 300 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170420300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172707780 | ||||||||
| FaxNumber: | 7172729746 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 N 4TH ST | ||||||||
| Address2: | 4TH AND WILLOW STREETS | ||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170464808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172740474 | ||||||||
| FaxNumber: | 7172740673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2012 | ||||||||
| LastUpdateDate: | 11/25/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOGER | ||||||||
| AuthorizedOfficialFirstName: | JODY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7172707780 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 001864024 | 05 | PA | MEDICAID |