MEDICARE: KODIAK ISLAND HEALTH CARE FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	173000000X	Legal Medicine	297211	AK
2	261QF0400X	Federally Qualified Health Center (FQHC)	297211	AK
3	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326047044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KODIAK ISLAND HEALTH CARE FOUNDATION

Provider Business Mailing Address
First Line	:	1911 E REZANOF DR.
Second Line	:
City	:	KODIAK
State	:	AK
Zip	:	99615
Country	:	US
Telephone Number	:	907-481-5000
Fax Number	:	907-481-5030

Provider Business Practice Location Address
First Line	:	1911 E REZANOF DR.
Second Line	:
City	:	KODIAK
State	:	AK
Zip	:	99615
Country	:	US
Telephone Number	:	907-481-5000
Fax Number	:	907-481-5030

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CAROL AUSTERMAN
Credential	:
Telephone Number	:	907-481-5002

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	06/24/2022

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