Provider Demographics
NPI:1013998780
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:GOOD SAMARITAN SOCIETY - JEFFERSONTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:RAYE NAE
Authorized Official - Middle Name:
Authorized Official - Last Name:NYLANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-362-3100
Mailing Address - Street 1:4800 WEST 57TH STREET P.O. BOX 5038
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5038
Mailing Address - Country:US
Mailing Address - Phone:605-362-3100
Mailing Address - Fax:605-362-3265
Practice Address - Street 1:3500 GOOD SAMARITAN WAY
Practice Address - Street 2:
Practice Address - City:JEFFERSONTOWN
Practice Address - State:KY
Practice Address - Zip Code:40299-6117
Practice Address - Country:US
Practice Address - Phone:502-267-7403
Practice Address - Fax:502-267-8978
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-09
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000054394OtherBLUE CROSS BLUE SHIELD
KY12501466Medicaid
KY00000054394OtherANTHEM BLUE CROSS BLUE SH
KY000000054394OtherBLUE CROSS BLUE SHIELD
KY0140910028Medicare NSC