Basic Information
| Provider Information | |||||||||
| NPI: | 1225266588 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORDOVA COMMUNITY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORDOVA COMMUNITY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 CHASE AVE | ||||||||
| Address2: | |||||||||
| City: | CORDOVA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995740160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074248000 | ||||||||
| FaxNumber: | 9074248116 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 CHASE AVE | ||||||||
| Address2: | |||||||||
| City: | CORDOVA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995740160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074248000 | ||||||||
| FaxNumber: | 9074248116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | SANDERS | ||||||||
| AuthorizedOfficialFirstName: | HANNAH | ||||||||
| AuthorizedOfficialMiddleName: | JOANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9074248200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | HS07LT | 05 | AK | MEDICAID | HS07OP | 05 | AK | MEDICAID | HS07SB | 05 | AK | MEDICAID | HS07IP | 05 | AK | MEDICAID |