Provider Demographics
NPI:1851870984
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:GOOD SAMARITAN SOCIETY - LAKOTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:TRIBBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-362-3900
Mailing Address - Street 1:608 4TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:LAKOTA
Mailing Address - State:ND
Mailing Address - Zip Code:58344-7500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:608 4TH AVE SW
Practice Address - Street 2:
Practice Address - City:LAKOTA
Practice Address - State:ND
Practice Address - Zip Code:58344-7500
Practice Address - Country:US
Practice Address - Phone:701-247-2902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000OtherMEDICARE PART B