Provider Demographics
NPI:1952309528
Name:GOOD SAMARITAN HOSPITAL
Entity Type:Organization
Organization Name:GOOD SAMARITAN HOSPITAL
Other - Org Name:SAMARITAN CENTER - PETERSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP BEHAVIORAL HEALTH/SPEC PROJECTS
Authorized Official - Prefix:MR
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 1:611 E MAIN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:PETERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47567-1267
Practice Address - Country:US
Practice Address - Phone:812-354-8785
Practice Address - Fax:812-354-8786
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SAMARITAN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-08
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN4030101Y00000X, 101YA0400X, 1041C0700X, 2084P0800X
IN4030CMHC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN165526OtherMHN GROUP
IN192466000OtherMAGELLAN
IN000000574039OtherANTHEM PIN FOR THIS LOCATION
IN301936OtherVALUE OPTIONS FACILITY
IN100270140CMedicaid
IN100270140GMedicaid
IN444530Medicare PIN