Provider Demographics
NPI:1710244843
Name:GOOD SAMARITAN HOSPITAL CORVALLIS
Entity Type:Organization
Organization Name:GOOD SAMARITAN HOSPITAL CORVALLIS
Other - Org Name:SAMARITAN SPORTS MEDICINE-V
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-768-5009
Mailing Address - Street 1:325 VALLEY FOOTBALL CTR
Mailing Address - Street 2:ROOM 122-123
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97331-8544
Mailing Address - Country:US
Mailing Address - Phone:541-737-4527
Mailing Address - Fax:541-737-0864
Practice Address - Street 1:325 VALLEY FOOTBALL CTR
Practice Address - Street 2:ROOM 122-123
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97331-8544
Practice Address - Country:US
Practice Address - Phone:541-737-4527
Practice Address - Fax:541-737-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500651544Medicaid
OR500651544Medicaid