=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730833088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD SAMARITAN HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2022
-----------------------------------------------------
Last Update Date | 02/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3815 HIGHLAND AVE
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515-1500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-575-3323
-----------------------------------------------------
Fax | 630-645-4602
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 93548
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60673-3548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-575-3323
-----------------------------------------------------
Fax | 630-645-4602
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLER
-----------------------------------------------------
Name | YOLANDA SALLIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-575-3323
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------