1902156482 NPI number — GOOD SAMARITAN CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902156482 NPI number — GOOD SAMARITAN CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOOD SAMARITAN CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902156482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
418 GRAND PARK DRIVE
Provider Second Line Business Mailing Address:
SUITE 311
Provider Business Mailing Address City Name:
PARKERSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26105-4000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-834-3986
Provider Business Mailing Address Fax Number:
304-834-3987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
418 GRAND PARK DRIVE
Provider Second Line Business Practice Location Address:
SUITE 311
Provider Business Practice Location Address City Name:
PARKERSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26105-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-834-3986
Provider Business Practice Location Address Fax Number:
304-834-3987
Provider Enumeration Date:
09/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
304-834-3986

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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