Healthcare Provider Details

I. General information

NPI: 1982957015
Provider Name (Legal Business Name): PROVIDENCE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2012
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 FIRST AVE
SEWARD AK
99664-0365
US

IV. Provider business mailing address

PO BOX 430
SEWARD AK
99664-0430
US

V. Phone/Fax

Practice location:
  • Phone: 907-224-5205
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number2310
License Number StateAK

VIII. Authorized Official

Name: DONALD WAYNE ANDERSON JR.
Title or Position: ASSISTANT SECRETARY OF ENROLLMENTS
Credential:
Phone: 425-358-9786