Provider Demographics
NPI:1437102399
Name:GOOD SAMARITAN COMMUNITY HEALTHCARE
Entity Type:Organization
Organization Name:GOOD SAMARITAN COMMUNITY HEALTHCARE
Other - Org Name:GOOD SAMARITAN CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LONG
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:253-697-2102
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0137
Mailing Address - Country:US
Mailing Address - Phone:253-697-5502
Mailing Address - Fax:253-697-5510
Practice Address - Street 1:16515 MERIDIAN E
Practice Address - Street 2:SUITE 104A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-6251
Practice Address - Country:US
Practice Address - Phone:253-697-3030
Practice Address - Fax:253-697-8190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Not Answered207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Not Answered363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7121940Medicaid
WA0122524OtherL & I NUMBER
WA3006G0OtherREGENCE GROUP RIDER NUMBE
WA3006G0OtherREGENCE GROUP RIDER NUMBE