Basic Information
| Provider Information | |||||||||
| NPI: | 1760719116 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH EAST ALASKA REGIONAL HEALTH CONSORTIUM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ALICIA ROBERTS MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 13004 KLAWOCK HOLLIS HWY | ||||||||
| Address2: | |||||||||
| City: | KLAWOCK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077554800 | ||||||||
| FaxNumber: | 9077554806 | ||||||||
| Practice Location | |||||||||
| Address1: | 13004 KLAWOCK HOLLIS HWY | ||||||||
| Address2: | |||||||||
| City: | KLAWOCK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077554800 | ||||||||
| FaxNumber: | 9077554806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2009 | ||||||||
| LastUpdateDate: | 06/11/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SEARLS | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9074634061 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 70206 | AK | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | MDG631 | 05 | AK | MEDICAID |