Healthcare Provider Details

I. General information

NPI: 1497685747
Provider Name (Legal Business Name): GOOD SAMARITAN HOSPITAL PHYSICIAN SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 TRIM MASTERS DR
LAWRENCEVILLE IL
62439-9501
US

IV. Provider business mailing address

1160 E SAINT CLAIR ST
VINCENNES IN
47591-4853
US

V. Phone/Fax

Practice location:
  • Phone: 618-943-7900
  • Fax:
Mailing address:
  • Phone: 812-885-3325
  • Fax: 812-885-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ADAM THACKER
Title or Position: CEO
Credential:
Phone: 812-882-5220