Provider Demographics
NPI:1962453134
Name:GOOD SAMARITAN HOSPITAL CORVALLIS
Entity type:Organization
Organization Name:GOOD SAMARITAN HOSPITAL CORVALLIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO-GSRMC
Authorized Official - Prefix:
Authorized Official - First Name:SY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-768-6768
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:541-768-5111
Mailing Address - Fax:
Practice Address - Street 1:3600 NW SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3737
Practice Address - Country:US
Practice Address - Phone:541-768-5111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SAMARITAN HOSPITAL CORVALLIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-13
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14 1074273R00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500400202Medicaid
OR500400202Medicaid
ORR164041Medicare UPIN