Provider Demographics
NPI:1750374914
Name:SAMARITAS
Entity type:Organization
Organization Name:SAMARITAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:CEDERSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-823-7700
Mailing Address - Street 1:8131 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-2610
Mailing Address - Country:US
Mailing Address - Phone:313-823-7700
Mailing Address - Fax:313-823-9604
Practice Address - Street 1:1950 32ND ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-7909
Practice Address - Country:US
Practice Address - Phone:616-452-5900
Practice Address - Fax:616-452-4271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI414021314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2150464Medicaid
MI09890OtherBCBS
235458Medicare ID - Type Unspecified