Healthcare Provider Details

I. General information

NPI: 1093043234
Provider Name (Legal Business Name): CENTRAL PENINSULA GENERAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2009
Last Update Date: 05/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 N FIREWEED ST SUITE C
SOLDOTNA AK
99669-7540
US

IV. Provider business mailing address

289 N FIREWEED ST SUITE C
SOLDOTNA AK
99669-7540
US

V. Phone/Fax

Practice location:
  • Phone: 907-714-4075
  • Fax:
Mailing address:
  • Phone: 907-714-4075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number937105
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number937105
License Number StateAK

VIII. Authorized Official

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