Basic Information
| Provider Information | |||||||||
| NPI: | 1659825776 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENINSULA COMMUNITY HEALTH SERVICES OF ALASKA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENAI | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2949 | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996692949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072607300 | ||||||||
| FaxNumber: | 9072607301 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 FRONTAGE RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | KENAI | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996119104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072833600 | ||||||||
| FaxNumber: | 9072833601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2016 | ||||||||
| LastUpdateDate: | 08/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | MAGEE | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 9072607300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENINSULA COMMUNITY HEALTH SERVICES OF ALASKA, INC. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 920499 | AK | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.