Basic Information
| Provider Information | |||||||||
| NPI: | 1790844033 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE PETERSBURG MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PETERSBURG GENERAL HOSPITAL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 FRAM STREET | ||||||||
| Address2: | PO BOX 589 | ||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998330589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077724291 | ||||||||
| FaxNumber: | 9077723085 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 FRAM STREET | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998330589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077724291 | ||||||||
| FaxNumber: | 9077723085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 10/08/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANTIEGNE | ||||||||
| AuthorizedOfficialFirstName: | CARMEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9077724291 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WH0200X | AK | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Home Health | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | HH0057 | 05 | AK | MEDICAID |