Basic Information
| Provider Information | |||||||||
| NPI: | 1124201199 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YUKON KUSKOKWIM HEALTH CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4700 BUSINESS PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995037176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436000 | ||||||||
| FaxNumber: | 9075436117 | ||||||||
| Practice Location | |||||||||
| Address1: | 246 KWIGUK STREET | ||||||||
| Address2: | EMMONAK SUBREGIONAL CLINIC | ||||||||
| City: | EMMONAK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436000 | ||||||||
| FaxNumber: | 9075436117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2007 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PELTOLA | ||||||||
| AuthorizedOfficialFirstName: | GENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9075436000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | YKHC-EMMONAK SUBREGIONAL CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.