Healthcare Provider Details

I. General information

NPI: 1821429994
Provider Name (Legal Business Name): GOOD SAMARITAN PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2013
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FAIRVIEW CIR
LEBANON PA
17042-9581
US

IV. Provider business mailing address

PO BOX 300
LEBANON PA
17042-0300
US

V. Phone/Fax

Practice location:
  • Phone: 717-279-7303
  • Fax: 717-279-7471
Mailing address:
  • Phone: 717-270-7780
  • Fax: 717-274-9746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JODY M BOGER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 717-270-7780