Provider Demographics
NPI:1821442179
Name:MIDWEST EMERGENCY GOOD SAMARITAN
Entity Type:Organization
Organization Name:MIDWEST EMERGENCY GOOD SAMARITAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:CRUZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-451-4208
Mailing Address - Street 1:PO BOX 8974
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-0974
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:817-563-3699
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:817-451-4208
Practice Address - Fax:817-563-3699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061115207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty