Basic Information
| Provider Information | |||||||||
| NPI: | 1831404805 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL PENINSULA GENERAL HOSPITAL | ||||||||
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| OtherOrganizationName: | CENTRAL PENINSULA FAMILY PRACTICE FIREWEED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 HOSPITAL PL | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996697559 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 245 N BINKLEY ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996697523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077144111 | ||||||||
| FaxNumber: | 9077144696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2010 | ||||||||
| LastUpdateDate: | 06/04/2012 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9077144723 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 0004 | 01 | AK | TRIWEST | OTHER | 155 | 01 | AK | BLUE CROSS | OTHER | MDG830 | 05 | AK | MEDICAID |