Provider Demographics
NPI:1942223482
Name:LEGACY GOOD SAMARITAN HOSPITAL AND MEDICAL CENTER
Entity Type:Organization
Organization Name:LEGACY GOOD SAMARITAN HOSPITAL AND MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CFO
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-415-5145
Mailing Address - Street 1:PO BOX 4037
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4037
Mailing Address - Country:US
Mailing Address - Phone:503-413-4048
Mailing Address - Fax:503-413-4449
Practice Address - Street 1:1015 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3025
Practice Address - Country:US
Practice Address - Phone:503-413-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY GOOD SAMARITAN HOSPITAL & MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14-0027273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR135199Medicaid
WA1022717Medicaid
ID0033387Medicaid
WA3200052Medicaid
CAXHSP30237Medicaid
OR138001700OtherREGENCE BLUE CROSS
CAXHSP40237Medicaid
WA3200052Medicaid
ORR0000ZBBVLMedicare PIN