Good Samaritan Family Health Center, Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Petersburg, IN
NPI 1710744263 · NPPES record last updated Mar 1, 2024
Key facts
- NPI
- 1710744263
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- GOOD SAMARITAN FAMILY HEALTH CENTER, INC
- Practice address
- 1810 E State Road 56
Petersburg, IN 47567-8378 - Phone
- (810) 494-9515
- Fax
- (812) 494-9514
- NPI assigned
- Mar 1, 2024
- Organization subpart
- Yes
- Parent organization (as reported)
- GOOD SAMARITAN FAMILY HEALTH CENTER, INC
Authorized official
- Name
- Jennifer Emmons
- Title
- Ceo
- Phone
- (812) 494-9501
Corporate family (same tax ID) 29
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
Federally qualified health center certification: CCN C51058
- Legal name
- GOOD SAMARITAN FAMILY HEALTH CENTER INC
- Doing business as
- FAMILY HEALTH CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Sep 12, 2024
- Last certification
- Sep 12, 2024
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Sep 25, 2017 in IN
- Enrollment address
- 1810 E State Road 56
FL 1
Petersburg, IN 47567-8378
All disclosed owners & managing parties 8
| Name | Role | Since | Share |
|---|---|---|---|
| Stanley Graber |
Corporate Officer |
Aug 21, 2024 | |
| Bridgett Bilskie |
W-2 Managing Employee |
Aug 21, 2024 | |
| Joseph Williams |
Corporate Director |
Aug 21, 2024 | |
| Stormey Wiegman |
W-2 Managing Employee |
Aug 21, 2024 | |
| Kolby Kerzan |
Corporate Director |
Aug 21, 2024 | |
| Jennifer Emmons |
5% Or Greater Direct Ownership Interest |
Aug 21, 2024 | 100% |
| Debbie Mills |
Corporate Director |
Aug 21, 2024 | |
| Traci French |
Corporate Officer |
Aug 21, 2024 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20240930001765 | IN | Part a Provider - Federally Qualified Health Center (FQHC) | 5294099321 | Practice locations: Petersburg, IN |
National Provider Directory
- Tax ID family
- Good Samaritan Family Health Center Inc
- Part of
- Good Samaritan Family Health Center Inc
Locations
1810 E State Road 56
Petersburg, IN 47567
Phone (810) 494-9515
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
1810 E State Road 56
Petersburg, IN 47567-8378
Mailing address
PO Box 556
Vincennes, IN 47591-0556
Phone (812) 494-9501
Other names
- Family Health Center
Other providers in Petersburg, IN
- Laryn Faulk
- Honesto K Fenol Jr.
- Heather Furniss
- Donald R Gatwood
- Good Samaritan Family Health Center, Inc
- Good Samaritan Family Health Center, Inc.
- Good Samaritan Hospital
- Good Samaritan Hospital
- Greene Specific Chiropractic Clinic PC
- Robert C Greene
All providers in Petersburg, IN · Federally Qualified Health Center (FQHC) in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 1, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.