Basic Information
| Provider Information | |||||||||
| NPI: | 1942368428 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YUKON KUSKOKWIM HEALTH CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AEROMED INTERNATIONAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 BUSINESS PARK BLVD | ||||||||
| Address2: | E25 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995037124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076777501 | ||||||||
| FaxNumber: | 9076777502 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 BUSINESS PARK BLVD | ||||||||
| Address2: | E25 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995037124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076777501 | ||||||||
| FaxNumber: | 9076777502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 03/03/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PELTOLA | ||||||||
| AuthorizedOfficialFirstName: | GENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9075436020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | YUKON KUSKOKWIM HEALTH CORP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | AK | N | Transportation Services | Ambulance | Land Transport | 347E00000X | N | Transportation Services | Transportation Broker | 3416A0800X | AK | Y | Transportation Services | Ambulance | Air Transport |
ID Information
| ID | Type | State | Issuer | Description | AA0050 | 05 | AK | MEDICAID | AA5060 | 05 | AK | MEDICAID | TRO151 | 05 | AK | MEDICAID |