Healthcare Provider Details

I. General information

NPI: 1528181369
Provider Name (Legal Business Name): KENAI MEDICAL CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 FRONTAGE RD STE 123
KENAI AK
99611-7755
US

IV. Provider business mailing address

805 FRONTAGE RD STE 123
KENAI AK
99611-7755
US

V. Phone/Fax

Practice location:
  • Phone: 907-283-4611
  • Fax: 907-283-3992
Mailing address:
  • Phone: 907-283-4611
  • Fax: 907-283-3992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7331
License Number StateAK

VIII. Authorized Official

Name: DR. PETER O. HANSEN
Title or Position: PRESIDENT
Credential: M. D.
Phone: 907-283-4611