Provider Demographics
NPI:1336576875
Name:GOOD SAMARITAN HOSPITAL PHYSICIAN SERVICES, INC
Entity Type:Organization
Organization Name:GOOD SAMARITAN HOSPITAL PHYSICIAN SERVICES, INC
Other - Org Name:GOOD SAMARITAN HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-882-5220
Mailing Address - Street 1:1160 E SAINT CLAIR ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-4853
Mailing Address - Country:US
Mailing Address - Phone:812-885-3453
Mailing Address - Fax:812-885-8499
Practice Address - Street 1:520 S 7TH ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1038
Practice Address - Country:US
Practice Address - Phone:812-882-5220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SAMARITAN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-30
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207Q00000X, 207R00000X, 363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270150Medicaid
IN941140Medicare PIN