Provider Demographics
NPI:1609896174
Name:LEGACY GOOD SAMARITAN HOSPITAL AND MEDICAL CENTER
Entity Type:Organization
Organization Name:LEGACY GOOD SAMARITAN HOSPITAL AND MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CFO
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-415-5145
Mailing Address - Street 1:1040 NW 22ND AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-413-4048
Mailing Address - Fax:503-413-4449
Practice Address - Street 1:1040 NW 22ND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3057
Practice Address - Country:US
Practice Address - Phone:503-413-3958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY GOOD SAMARITAN HOSPITAL AND MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-20
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0001427-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3806051OtherNCPDP