Basic Information
| Provider Information | |||||||||
| NPI: | 1639249683 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOONAH MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOONAH INDIAN ASSOCIATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602 | ||||||||
| Address2: | |||||||||
| City: | HOONAH | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998290602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079453235 | ||||||||
| FaxNumber: | 9079453239 | ||||||||
| Practice Location | |||||||||
| Address1: | 568 RAVIN DRIVE | ||||||||
| Address2: | |||||||||
| City: | HOONAH | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998290602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079453235 | ||||||||
| FaxNumber: | 9079453239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | LEAD PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 9079453235 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | P.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 1505 | AK | X | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 207Q00000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CL2382 | 05 | AK | MEDICAID |