Basic Information
| Provider Information | |||||||||
| NPI: | 1922544329 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SEARHC AICS MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CHANNEL DRIVE STE 300 | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074634000 | ||||||||
| FaxNumber: | 9074631510 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 WOOD STREET | ||||||||
| Address2: | STE 100 | ||||||||
| City: | WRANGELL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078744700 | ||||||||
| FaxNumber: | 9078744719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2017 | ||||||||
| LastUpdateDate: | 12/31/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP/CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9074634000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1663301 | 05 | AK | MEDICAID | 70206 | 01 | AK | BUSINESS LICENSE | OTHER |