The Evangelical Lutheran Good Samaritan Society

Primary specialty

Community Based Hospice Care AgencyTaxonomy code 251G00000X

Legal business name

THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY

Doing business as

Good Samaritan Society-Prescott Hospice

Practice address

1065 Ruth St
Suite 108-109
Prescott, AZ 86301

Phone

(928) 778-5655

Fax

(928) 445-2497

NPI assigned

Jul 31, 2007

Last updated

Sep 20, 2021By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

George Grant Tribble

Title

Exeutive VP

Phone

(605) 362-3900

Specialties & licenses 1

Addresses

Other names 1

• Good Samaritan Society-Prescott Hospice Doing business as

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in AZ

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1326238874. Details of each certification follow.

• CCN 031584 Hospice · Active · Details

Hospice certification: CCN 031584

Legal name

THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY

Doing business as

GOOD SAMARITAN SOCIETY - PRESCOTT HOSPICE

Certification status

Active

Provider type (POS)

Hospice

Participating since

Jul 15, 2009

Last certification

Sep 11, 2020

Ownership / control type

Non-Profit - Private

Organization structure

CorporationNon-profit

Incorporated

Sep 29, 1922 in ND

Enrollment address

1065 Ruth St
Prescott, AZ 86301-1729

Listed as

Good Samaritan Society Prescott HospiceCCN 031584 · All quality measures

Ownership

Non-Profit

Certified

Jul 15, 2009

Medicare certification status

ActiveFrom the Provider of Services file

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

Good Samaritan Home210 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 2

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

• The Evangelical Lutheran Good Samaritan Society

  dba Willow Wind

  • Assisted Living Facility
  • Prescott, AZ
  • NPI 1588645600
  NPD tax ID
• The Evangelical Lutheran Good Samaritan Society

  dba The Gables

  • Assisted Living Facility
  • Mesa, AZ
  • NPI 1780961037
  NPD tax ID

Locations

All disclosed owners & managing parties 23

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

• Fred S. Markham, MD

  • Internal Medicine Physician
  • Prescott, AZ
  • NPI 1679538995

  Contracted Managing Employee

  CMS ownership

All facility ownership & control disclosures 108

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

Showing 100 of 108 facilities.

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1185840000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1632096000000",
    "number": "1326238874",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4800 W 57TH ST",
            "city": "SIOUX FALLS",
            "state": "SD",
            "postal_code": "571082239"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1065 RUTH ST",
            "address_2": "SUITE 108-109",
            "city": "PRESCOTT",
            "state": "AZ",
            "postal_code": "86301",
            "telephone_number": "928-778-5655",
            "fax_number": "928-445-2497"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-07-31",
        "last_updated": "2021-09-20",
        "certification_date": "2021-09-20",
        "status": "A",
        "authorized_official_last_name": "TRIBBLE",
        "authorized_official_first_name": "GEORGE",
        "authorized_official_middle_name": "GRANT",
        "authorized_official_title_or_position": "EXEUTIVE VP",
        "authorized_official_telephone_number": "605-362-3900"
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": "AZ",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1068.1",
            "affiliationName": "Cobius Healthcare Solutions",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "2720 Dundee Rd # 302",
            "city": "Northbrook",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600622609",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Good Samaritan Society-Prescott Hospice",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Good Samaritan Society-Prescott Hospice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Community Based Hospice Care Agency in Prescott, AZ
• Providers in Prescott, AZ by specialty
• Community Based Hospice Care Agency in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 20, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.