Provider Demographics
NPI:1861490435
Name:GOOD SAMARITAN HOSPITAL
Entity Type:Organization
Organization Name:GOOD SAMARITAN HOSPITAL
Other - Org Name:SAMARITAN CENTER-BUNTIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP BEHAVIORAL HEALTH/SPEC PROJECTS
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-886-6800
Mailing Address - Street 1:515 BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1034
Mailing Address - Country:US
Mailing Address - Phone:812-886-6800
Mailing Address - Fax:812-886-6809
Practice Address - Street 1:121 BUNTIN ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1320
Practice Address - Country:US
Practice Address - Phone:812-885-2700
Practice Address - Fax:812-885-2716
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SAMARITAN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-08
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN4030101YA0400X, 104100000X, 1041C0700X
IN4030CMHC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270140GMedicaid
IN326003OtherVALUE OPTIONS
IN000000574042OtherANTHEM PIN FOR THIS LOCATION
IN100270140MMedicaid
IN165526OtherMHN GROUP
IN100270140MMedicaid