Provider Demographics
NPI:1568643021
Name:ST. MARYS GOOD SAMARITAN INC
Entity Type:Organization
Organization Name:ST. MARYS GOOD SAMARITAN INC
Other - Org Name:CARBONDALE BEH. HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MNG BILLING
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-436-6267
Mailing Address - Street 1:1034 E NOLEMAN ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3348
Mailing Address - Country:US
Mailing Address - Phone:618-436-6267
Mailing Address - Fax:
Practice Address - Street 1:1034 E NOLEMAN ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3348
Practice Address - Country:US
Practice Address - Phone:618-436-6267
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X, 101Y00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3928382OtherBCBS OF ILLINOIS