Provider Demographics
NPI:1720161086
Name:SAMARITAN FAMILY CARE INC
Entity Type:Organization
Organization Name:SAMARITAN FAMILY CARE INC
Other - Org Name:FAMILY MEDICINE OF VANDALIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDEN
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUNIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-208-8273
Mailing Address - Street 1:810 FALLS CREEK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-8600
Mailing Address - Country:US
Mailing Address - Phone:937-454-0317
Mailing Address - Fax:937-454-1668
Practice Address - Street 1:810 FALLS CREEK DR
Practice Address - Street 2:SUITE B
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-8600
Practice Address - Country:US
Practice Address - Phone:937-454-0317
Practice Address - Fax:937-454-1668
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAMARITAN FAMILY CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-23
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2552134Medicaid
OH9931742Medicare PIN