Basic Information
| Provider Information | |||||||||
| NPI: | 1598397911 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BARTLETT REGIONAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | 1115 SUD WAIVER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3260 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077968436 | ||||||||
| FaxNumber: | 9077968477 | ||||||||
| Practice Location | |||||||||
| Address1: | 3250 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077968690 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2020 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEITH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9077968900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BARTLETT REGIONAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.