Basic Information
| Provider Information | |||||||||
| NPI: | 1013077080 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORDOVA COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CORDOVA COMMUNITY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 160 | ||||||||
| Address2: | |||||||||
| City: | CORDOVA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995740160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074248000 | ||||||||
| FaxNumber: | 9074248405 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 CHASE AVE | ||||||||
| Address2: | |||||||||
| City: | CORDOVA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995740160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074248000 | ||||||||
| FaxNumber: | 9074248405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRYANT | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 9074248000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | 280775 | AK | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | PH002 | 05 | AK | MEDICAID | 1996576 | 01 | PK | OTHER |