MEDICARE: GOOD SAMARITAN HEALTH CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center	261QH0100X	IN

General Provider Information

NPI Number	:	1871717439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOOD SAMARITAN HEALTH CLINIC

Provider Business Mailing Address
First Line	:	11 EASTERN AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46201-1871
Country	:	US
Telephone Number	:	317-638-2862
Fax Number	:	317-638-7993

Provider Business Practice Location Address
First Line	:	2716 E. WASHINGTON STREET
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46206-1871
Country	:	US
Telephone Number	:	317-638-2862
Fax Number	:	317-263-9907

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. DANIEL J. EVANS
Credential	:	E.D
Telephone Number	:	317-638-2862

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	08/22/2020

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