Basic Information
Provider Information | |||||||||
NPI: | 1962570903 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CORDOVA COMMUNITY MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CORDOVA COMMUNITY MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 160 | ||||||||
Address2: |   | ||||||||
City: | CORDOVA | ||||||||
State: | AK | ||||||||
PostalCode: | 99574 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 602 CHASE AVENUE | ||||||||
Address2: |   | ||||||||
City: | CORDOVA | ||||||||
State: | AK | ||||||||
PostalCode: | 995740160 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074248000 | ||||||||
FaxNumber: | 9074248116 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2006 | ||||||||
LastUpdateDate: | 06/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SANDERS | ||||||||
AuthorizedOfficialFirstName: | HANNAH | ||||||||
AuthorizedOfficialMiddleName: | JOANN | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9074248200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 06/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X |   | AK | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
No ID Information.