Provider Demographics
NPI:1881679579
Name:GOOD SAMARITAN PONTIAC
Entity Type:Organization
Organization Name:GOOD SAMARITAN PONTIAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WITTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:815-844-5121
Mailing Address - Street 1:1225 S EWING DR
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9701
Mailing Address - Country:US
Mailing Address - Phone:815-844-5121
Mailing Address - Fax:815-419-6000
Practice Address - Street 1:1225 S EWING DR
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9701
Practice Address - Country:US
Practice Address - Phone:815-844-5121
Practice Address - Fax:815-419-6000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1630299313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0010942Medicaid
IL145930Medicare ID - Type UnspecifiedPROVIDER NUMBER