=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780608216
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY GOOD SAMARITAN HOSPITAL AND MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 02/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 NW 22ND AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97210-3025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-413-7711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4037
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97208-4037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-413-4048
-----------------------------------------------------
Fax | 503-413-4449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP FINANCE
-----------------------------------------------------
Name | SARAH JENSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-415-5145
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204F00000X
-----------------------------------------------------
Taxonomy Name | Transplant Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | NA
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 14-0027
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 14-0027
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------