Provider Demographics
NPI:1437131349
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:GOOD SAMARITAN SOCIETY - ROSEVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:RAYE NAE
Authorized Official - Middle Name:
Authorized Official - Last Name:NYLANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-362-3100
Mailing Address - Street 1:PO BOX 5038
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5038
Mailing Address - Country:US
Mailing Address - Phone:605-362-3100
Mailing Address - Fax:605-362-3265
Practice Address - Street 1:1415 COUNTY ROAD B W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4216
Practice Address - Country:US
Practice Address - Phone:651-631-1616
Practice Address - Fax:651-631-1899
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-16
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1026654OtherPREFERRED ONE INPATIENT
MN7100093OtherPMAP EVERCARE
MN5A23GO9OtherCOMPREHENSIVE CARE
MN82516300Medicaid
MN1026655OtherPREFERRED ONE
MN7111788OtherMEDICA
MN5A23GOOtherBLUE CROSS BLUE SHIELD
MN030443Medicaid
MNNH0088OtherUCARE
MN245089Medicare Oscar/Certification
MN5A23GOOtherBLUE CROSS BLUE SHIELD