Healthcare Provider Details

I. General information

NPI: 1487758801
Provider Name (Legal Business Name): GOOD SAMARITAN REGIONAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GOOD SAMARITAN WAY
MOUNT VERNON IL
62864-2402
US

IV. Provider business mailing address

PO BOX 503927
SAINT LOUIS MO
63150-0001
US

V. Phone/Fax

Practice location:
  • Phone: 618-899-4600
  • Fax: 618-532-9365
Mailing address:
  • Phone: 618-899-4600
  • Fax: 618-532-9365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0004705
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0004705
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number0004705
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number0004705
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0004705
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number0004705
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number0004705
License Number StateIL
# 8
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0004705
License Number StateIL

VIII. Authorized Official

Name: MR. JEREMY BRADFORD
Title or Position: PRESIDENT
Credential:
Phone: 618-899-1001