=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528181369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENAI MEDICAL CENTER INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 FRONTAGE RD STE 123
-----------------------------------------------------
City | KENAI
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99611-7755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-283-4611
-----------------------------------------------------
Fax | 907-283-3992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 805 FRONTAGE RD STE 123
-----------------------------------------------------
City | KENAI
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99611-7755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-283-4611
-----------------------------------------------------
Fax | 907-283-3992
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PETER O. HANSEN
-----------------------------------------------------
Credential | M. D.
-----------------------------------------------------
Telephone | 907-283-4611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 7331
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------