Provider Demographics
NPI:1982154993
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:GOOD SAMARITAN SOCIETY - BARBOUR COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP - FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIBBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-362-3100
Mailing Address - Street 1:4800 W 57TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2239
Mailing Address - Country:US
Mailing Address - Phone:605-362-3100
Mailing Address - Fax:
Practice Address - Street 1:216 SAMARITAN CIR
Practice Address - Street 2:
Practice Address - City:BELINGTON
Practice Address - State:WV
Practice Address - Zip Code:26250-8141
Practice Address - Country:US
Practice Address - Phone:304-823-2555
Practice Address - Fax:304-823-3136
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0002975000Medicaid
515116Medicare Oscar/Certification