Healthcare Provider Details

I. General information

NPI: 1609897339
Provider Name (Legal Business Name): GOOD SAMARITAN REGIONAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
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:
Mailing address:
  • Phone: 618-899-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number0004705
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number0004705
License Number StateIL

VIII. Authorized Official

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