Provider Demographics
NPI:1487758801
Name:GOOD SAMARITAN REGIONAL HEALTH CENTER
Entity type:Organization
Organization Name:GOOD SAMARITAN REGIONAL HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-899-1001
Mailing Address - Street 1:PO BOX 503927
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-0001
Mailing Address - Country:US
Mailing Address - Phone:618-899-4600
Mailing Address - Fax:618-532-9365
Practice Address - Street 1:1 GOOD SAMARITAN WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2402
Practice Address - Country:US
Practice Address - Phone:618-899-4600
Practice Address - Fax:618-532-9365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0004705208100000X, 2084N0400X, 207RI0011X, 2085R0001X, 2085R0202X, 227800000X, 227900000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGroup - Single Specialty
No227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4115179OtherBLUE CROSS BLUE SHIELD
IL33898OtherGROUP HEALTH PLAN
IL=========017OtherTRICARE PROVIDER NUMBER
IL=========017OtherTRICARE PROVIDER NUMBER
IL247570OtherHEALTHLINK NUMBER
IL827310Medicare ID - Type UnspecifiedMEDICARE PART B
IL827320Medicare ID - Type UnspecifiedMEDICARE PART B
IL4115179OtherBLUE CROSS BLUE SHIELD
IL=========017OtherTRICARE PROVIDER NUMBER
IL827300Medicare ID - Type UnspecifiedMEDICARE PART B