Provider Demographics
NPI:1407096951
Name:GOOD SAMARITAN PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:GOOD SAMARITAN PHYSICIAN SERVICES
Other - Org Name:WELLSPAN CARDIOTHORACIC SURGERY - LEBANON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-270-7780
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-0300
Mailing Address - Country:US
Mailing Address - Phone:717-270-7780
Mailing Address - Fax:717-274-9746
Practice Address - Street 1:4TH & WALNUT STREETS
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-6123
Practice Address - Country:US
Practice Address - Phone:717-270-3751
Practice Address - Fax:717-270-3754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-24
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001864024Medicaid
PA047659Medicare PIN