Healthcare Provider Details

I. General information

NPI: 1679728588
Provider Name (Legal Business Name): GOOD SAMARITIAN PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 NORMAN DR SUITE 3
LEBANON PA
17042-7559
US

IV. Provider business mailing address

PO BOX 300
LEBANON PA
17042-0300
US

V. Phone/Fax

Practice location:
  • Phone: 717-270-7908
  • Fax: 717-272-1734
Mailing address:
  • Phone: 717-270-7780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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