Healthcare Provider Details

I. General information

NPI: 1770723967
Provider Name (Legal Business Name): CENTRAL PENINSULA GENERAL HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2009
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 LAKE ST
KENAI AK
99611-6937
US

IV. Provider business mailing address

506 LAKE ST
KENAI AK
99611-6937
US

V. Phone/Fax

Practice location:
  • Phone: 907-714-4030
  • Fax: 907-335-0064
Mailing address:
  • Phone: 907-714-4030
  • Fax: 907-335-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number926294
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number926294
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number926294
License Number StateAK

VIII. Authorized Official

Name: RICHARD DAVIS
Title or Position: CEO
Credential:
Phone: 907-714-4723