MEDICARE: PIH HEALTH GOOD SAMARITAN HOSPITAL

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282N00000X	General Acute Care Hospital	930000071	CA

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1508859323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIH HEALTH GOOD SAMARITAN HOSPITAL

Provider Business Mailing Address
First Line	:	1225 WILSHIRE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-1901
Country	:	US
Telephone Number	:	213-977-2121
Fax Number	:	213-202-7118

Provider Business Practice Location Address
First Line	:	1225 WILSHIRE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-1901
Country	:	US
Telephone Number	:	213-977-2121
Fax Number	:	213-202-7118

Authorized Official
Title or Position	:	SPECIAL PROJECTS
Name	:	SUSANNE (SUE) R PONCE (AKA CARLSON)
Credential	:
Telephone Number	:	562-698-0811

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	07/26/2021

1225 WILSHIRE BLVD , DEPARTMENT OF RADIATION ONCOLOGY
LOS ANGELES, CA
90017-1901

Practice Phone: 213-977-2360
Practice Fax: 310-943-2703