Basic Information
Provider Information | |||||||||
NPI: | 1316995210 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MANIILAQ ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MANIILAQ HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 43 | ||||||||
Address2: |   | ||||||||
City: | KOTZEBUE | ||||||||
State: | AK | ||||||||
PostalCode: | 997520043 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074423321 | ||||||||
FaxNumber: | 9074427250 | ||||||||
Practice Location | |||||||||
Address1: | 436 5TH & TED STEVENS WAY | ||||||||
Address2: |   | ||||||||
City: | KOTZEBUE | ||||||||
State: | AK | ||||||||
PostalCode: | 997520043 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074423321 | ||||||||
FaxNumber: | 9074427250 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 10/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HANSEN | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: | JOHN | ||||||||
AuthorizedOfficialTitleorPosition: | DEPUTY ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 9074427150 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MANIILAQ ASSOCIATION | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 234051 | AK | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | HS19IP | 05 | AK |   | MEDICAID | HS19OP | 05 | AK |   | MEDICAID |