Basic Information
| Provider Information | |||||||||
| NPI: | 1700984614 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENINSULA COMMUNITY HEALTH SERVICES OF ALASKA, INC. | ||||||||
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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: | 230 E MARYDALE AVE | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996697648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072607300 | ||||||||
| FaxNumber: | 9072607301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 08/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | MAGEE | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 9072607300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 706967 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363LC1500X | 706967 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Community Health | 122300000X | 706967 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 103TC0700X | 706967 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 207Q00000X | 706967 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 1041C0700X | 706967 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363LP0808X | 737 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 174400000X | 2093 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 261QF0400X | 703967 | AK | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | HC5786 | 01 | AK | MEDICAID PROJECT CHOICE | OTHER | MH0156 | 05 | AK | MEDICAID | RH177FQ | 05 | AK | MEDICAID | DDG26FQ | 05 | AK | MEDICAID | K162666 | 01 | AK | MEDICARE PTAN | OTHER |