| Legacy Good Samaritan Providers | |
|
1200 Nw 23rd Ave Portland OR 97210-2906 | |
| (503) 413-7074 | |
| Not Available |
| Full Name | Legacy Good Samaritan Providers |
|---|---|
| Speciality | Clinic/Center |
| Location | 1200 Nw 23rd Ave, Portland, Oregon |
| Authorized Official Name and Position | Sarah Jensen (INTERIM CFO) |
| Authorized Official Contact | 5034155145 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Legacy Good Samaritan Providers Po Box 3808 Portland OR 97208-3808 Ph: (503) 413-3900 | Legacy Good Samaritan Providers 1200 Nw 23rd Ave Portland OR 97210-2906 Ph: (503) 413-7074 |
| NPI Number | 1679597108 |
|---|---|
| Provider Enumeration Date | 07/27/2006 |
| Last Update Date | 02/27/2018 |
| Medicare PECOS PAC ID | 0547179939 |
|---|---|
| Medicare Enrollment ID | O20190213002415 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1679597108 | NPI | - | NPPES |
| 007002000 | Other | OR | REGENCE BLUE CROSS |
| 226827 | Medicaid | OR | |
| 1016129 | Medicaid | WA | |
| 135199 | Medicaid | OR | |
| CK6664 | Other | OR | MEDICARE RAILROAD |
| 002868000 | Other | OR | REGENCE BLUE CROSS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | (* (Not Available)) | Secondary |
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
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