MEDICARE: CENTRAL PENINSULA GENERAL HOSPITAL INC.

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	275N00000X	Medicare Defined Swing Bed Hospital Unit	227830	AK
2	276400000X	Substance Use Disorder Rehabilitation Hospital Unit	311489	AK
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	227830	AK
4	282NR1301X	Rural Acute Care Hospital	227830	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	155	OTHER	AK	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	0004	OTHER	AK	TRICARE
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528062429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL PENINSULA GENERAL HOSPITAL INC.

Provider Business Mailing Address
First Line	:	250 HOSPITAL PL
Second Line	:
City	:	SOLDOTNA
State	:	AK
Zip	:	99669-7559
Country	:	US
Telephone Number	:	907-714-4404
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 HOSPITAL PL
Second Line	:
City	:	SOLDOTNA
State	:	AK
Zip	:	99669-7559
Country	:	US
Telephone Number	:	907-714-4404
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RICK DAVIS
Credential	:
Telephone Number	:	907-714-4723

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	02/25/2012

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