Provider Demographics
NPI:1679597108
Name:LEGACY GOOD SAMARITAN HOSPITAL AND MEDICAL CENTER
Entity type:Organization
Organization Name:LEGACY GOOD SAMARITAN HOSPITAL AND MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM CFO
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-415-5145
Mailing Address - Street 1:PO BOX 3808
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3808
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:1200 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2906
Practice Address - Country:US
Practice Address - Phone:503-413-7074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY GOOD SAMARITAN HOSPITAL AND MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR007002000OtherREGENCE BLUE CROSS
OR226827Medicaid
WA1016129Medicaid
OR135199Medicaid
ORCK6664OtherMEDICARE RAILROAD
OR002868000OtherREGENCE BLUE CROSS
OR007002000OtherREGENCE BLUE CROSS
WA7008279Medicaid
ORCK6664OtherMEDICARE RAILROAD
ORR117056Medicare PIN
WA7114978Medicaid