Provider Demographics
NPI:1760510424
Name:GOOD SAMARITAN PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:GOOD SAMARITAN PHYSICIAN SERVICES
Other - Org Name:WELLSPAN FAMILY MEDICINE - ELCO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-270-7780
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-0300
Mailing Address - Country:US
Mailing Address - Phone:717-270-7780
Mailing Address - Fax:717-274-9746
Practice Address - Street 1:6 PERRI AVE
Practice Address - Street 2:
Practice Address - City:MYERSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17067-3200
Practice Address - Country:US
Practice Address - Phone:717-949-6581
Practice Address - Fax:717-949-2816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001864024Medicaid
PA047659Medicare PIN