Basic Information
| Provider Information | |||||||||
| NPI: | 1215913801 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH EAST ALASKA REGIONAL HEALTH CONSORTIUM | ||||||||
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| OtherOrganizationName: | ALICIA ROBERTS MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CHANNEL DRIVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074634074 | ||||||||
| FaxNumber: | 9074631510 | ||||||||
| Practice Location | |||||||||
| Address1: | 7300 KLAWOCK-HOLLIS HWY | ||||||||
| Address2: | |||||||||
| City: | KLAWOCK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999250069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077554800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9074634000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261Q00000X | 70206 | AK | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | MDG632 | 05 | AK | MEDICAID | CL2276 | 05 | AK | MEDICAID | DDG225 | 05 | AK | MEDICAID | MDG631 | 05 | AK | MEDICAID |