Provider Demographics
NPI:1609897339
Name:GOOD SAMARITAN REGIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:GOOD SAMARITAN REGIONAL HEALTH CENTER
Other - Org Name:SSM HEALTH GOOD SAMARITAN HOSPITAL - MT. VERNON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-899-1001
Mailing Address - Street 1:PO BOX 503927
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-0001
Mailing Address - Country:US
Mailing Address - Phone:618-899-4600
Mailing Address - Fax:
Practice Address - Street 1:1 GOOD SAMARITAN WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2402
Practice Address - Country:US
Practice Address - Phone:618-899-4600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0004705273R00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL140112100OtherACS OWCP NUMBER
IL33898OtherGROUP HEALTH PLAN NUMBER
IL39584100OtherBLACK LUNG NUMBER
IL103233OtherHEALTHLINK NUMBER
IL003891OtherHEALTH ALLIANCE NUMBER
IL0014OtherBLUE CROSS/BLUE SHIELD
IL=========OtherTRICARE NUMBER
IL103233OtherHEALTHLINK NUMBER
IL39584100OtherBLACK LUNG NUMBER