NPIMap

Organization Active NPI

Good Samaritan Regional Health Center

Doing business as SSM Health Good Samaritan Hospital - Mt. Vernon

  • General Acute Care Hospital
  • Mount Vernon, IL
National Provider Identifier
1609897339
Registry record updated Nov 27, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Acute Care HospitalTaxonomy code 282N00000X
License
0004705 Issued in IL
Legal business name
GOOD SAMARITAN REGIONAL HEALTH CENTER
Doing business as
SSM Health Good Samaritan Hospital - Mt. Vernon
Practice address
1 Good Samaritan Way
Mount Vernon, IL 62864-2402
Phone
(618) 899-4600
NPI assigned
Jul 21, 2006
Last updated
Nov 27, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 27, 2023

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

Authorized official

Name
Mr. Jeremy Bradford
Title
President
Phone
(618) 899-1001

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Hospital Unit 273R00000X 0004705 IL
General Acute Care Hospital 282N00000X 0004705 IL Primary

Addresses

Primary practice location

1 Good Samaritan Way
Mount Vernon, IL 62864-2402

Mailing address

PO Box 503927
Saint Louis, MO 63150-0001
Phone (618) 899-4600

Other names 1

  • SSM Health Good Samaritan Hospital - Mt. Vernon Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040119000325 IL Part B Supplier - Clinic/Group Practice 1658272059 Receives reassigned benefits from 280 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Salem, IL; Mount Vernon, IL; Benton, IL
O20060320000309 IL Part A Provider - Hospital 1658272059 Practice locations: Mount Vernon, IL; Centralia, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1609897339. Details of each certification follow.

Hospital certification: CCN 140046

Legal name
GOOD SAMARITAN REGIONAL HEALTH CENTER
Doing business as
SSM HEALTH GOOD SAMARITAN HOSPITAL - MT. VERNON
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Jan 27, 2022
Beds
175
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Incorporated
Jun 30, 1958 in IL
Enrollment address
1 Good Samaritan Way
Mount Vernon, IL 62864-2402
Main/Primary Hospital Location
Hospital subgroups
General

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 4

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Care Compare: Hospital

Medicare Care Compare
Listed as
Good Samaritan Regional HLTH CenterCCN 140046 · All quality measures
Overall star rating
4 of 5
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory
Tax ID family
Good Samaritan Regional Health Center9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 19

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

NameRoleSinceShare
Jeremy Midura Individual Corporate DirectorBoard Member Dec 31, 2022
Susan Niepoetter Individual Corporate DirectorBoard Member Sep 14, 2024
Temple Jackson Individual W-2 Managing Employee Aug 2, 2021
Paula Friedman Individual Corporate DirectorBoard Member Dec 31, 2022
Damon R Harbison Individual Corporate OfficerPresident, Ex-Officio Jun 1, 2018
Eric Ibendahl Individual Corporate DirectorBoard Member Dec 31, 2020
Suzie Schmidt Individual Corporate DirectorBoard Member Dec 31, 2021
Rajendra Shroff Individual Corporate DirectorBoard Member Mar 16, 2023
Joseph Minerath Individual W-2 Managing EmployeeSystem Director of Reimbursement Jul 1, 2025
Jeremy M Fotheringham Individual Corporate DirectorBoard President Dec 31, 2022
SSM Health Care Corporation Organization, Saint Louis, MO Non-profit 5% Or Greater Indirect Ownership Interest Sep 1, 2015 100%
Monica Heinzman Individual Corporate DirectorBoard Member Sep 14, 2023
Matthew Flanigan Individual Corporate OfficerBoard Member Dec 31, 2020
Sudeep Nair Individual Corporate DirectorBoard Member Dec 31, 2020
Timothy Buller Individual Corporate OfficerRegional Cfo Fin Strategy Oct 1, 2015
SSM Regional Health Services Organization, Saint Louis, MO Non-profit 5% Or Greater Direct Ownership Interest Sep 1, 2015 100%
Tena Hoyt Individual Corporate OfficerBoard Member Dec 31, 2021
Jean-Benoit Houle Individual Corporate DirectorBoard Member Dec 31, 2022
Patricia Williams Individual Corporate DirectorBoard Member Nov 1, 2015

Owners & managing parties with NPI records 17

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

View all 17

Facilities with the same owner 30

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 30

Practitioners & affiliated clinicians

Affiliated clinicians 451

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 451

NPI Registry JSON

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

{
    "created_epoch": "1153440000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1701043200000",
    "number": "1609897339",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 503927",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631500001",
            "telephone_number": "618-899-4600"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 GOOD SAMARITAN WAY",
            "city": "MOUNT VERNON",
            "state": "IL",
            "postal_code": "628642402",
            "telephone_number": "618-899-4600"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GOOD SAMARITAN REGIONAL HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-21",
        "last_updated": "2023-11-27",
        "status": "A",
        "authorized_official_last_name": "BRADFORD",
        "authorized_official_first_name": "JEREMY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "618-899-1001",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "273R00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Unit",
            "state": "IL",
            "license": "0004705",
            "primary": false
        },
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": "IL",
            "license": "0004705",
            "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",
            "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": "SSM Health Good Samaritan Hospital - Mt. Vernon",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "SSM Health Good Samaritan Hospital - Mt. Vernon",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mount Vernon, IL

Sources for this page

Verify at the official NPI Registry.