Provider Demographics
NPI:1396767224
Name:GOOD SAMARITAN HOSPICE USA INC
Entity type:Organization
Organization Name:GOOD SAMARITAN HOSPICE USA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:GIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-767-4799
Mailing Address - Street 1:402 E DR HICKS BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-5763
Mailing Address - Country:US
Mailing Address - Phone:256-767-4799
Mailing Address - Fax:256-767-4798
Practice Address - Street 1:402 E DR HICKS BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-5763
Practice Address - Country:US
Practice Address - Phone:256-767-4799
Practice Address - Fax:256-767-4798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12948251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPIC1595EMedicaid
AL01200654OtherBLUE CROSS ALABAMA
ALPIC1595EMedicaid
AL011595Medicare Oscar/Certification