Healthcare Provider Details

I. General information

NPI: 1861490435
Provider Name (Legal Business Name): GOOD SAMARITAN HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 BUNTIN ST
VINCENNES IN
47591-1320
US

IV. Provider business mailing address

515 BAYOU ST
VINCENNES IN
47591-1034
US

V. Phone/Fax

Practice location:
  • Phone: 812-885-2700
  • Fax: 812-885-2716
Mailing address:
  • Phone: 812-886-6800
  • Fax: 812-886-6809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4030
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4030
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4030
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4030CMHC
License Number StateIN

VIII. Authorized Official

Name: JOHN MANNING
Title or Position: VP BEHAVIORAL HEALTH/SPEC PROJECTS
Credential:
Phone: 812-886-6800