MEDICARE: SOUTH PENINSULA HOSPITAL, INC.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy
1	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician
2	207X00000X	Orthopaedic Surgery Physician
3	208600000X	Surgery Physician
4	261QM1300X	Multi-Specialty Clinic/Center
5	282NC0060X	Critical Access Hospital

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

NPI Number	:	1679566269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH PENINSULA HOSPITAL, INC.

Provider Business Mailing Address
First Line	:	4300 BARTLETT STREET
Second Line	:
City	:	HOMER
State	:	AK
Zip	:	99603-7005
Country	:	US
Telephone Number	:	907-235-8101
Fax Number	:	907-235-0253

Provider Business Practice Location Address
First Line	:	4300 BARTLETT STREET
Second Line	:
City	:	HOMER
State	:	AK
Zip	:	99603-7005
Country	:	US
Telephone Number	:	907-235-8101
Fax Number	:	907-235-0253

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. RYAN SMITH
Credential	:
Telephone Number	:	907-235-0241

Provider Enumeration Date	:	08/29/2005
Last Update Date	:	02/07/2020

4300 BARTLETT ST , SOUTH PENISULA HOSPITAL
HOMER, AK
99603-7005

Practice Phone: 907-235-8101
Practice Fax: