=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164400750
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH PENINSULA HOSPITAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2006
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4201 BARTLETT ST
-----------------------------------------------------
City | HOMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99603-7015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-235-0369
-----------------------------------------------------
Fax | 907-235-0810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4300 BARTLETT ST
-----------------------------------------------------
City | HOMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99603-7005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | RYAN SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 907-235-0241
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HH2711
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------