Provider Demographics
NPI:1093043234
Name:CENTRAL PENINSULA GENERAL HOSPITAL
Entity type:Organization
Organization Name:CENTRAL PENINSULA GENERAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-714-4723
Mailing Address - Street 1:289 N FIREWEED ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7540
Mailing Address - Country:US
Mailing Address - Phone:907-714-4075
Mailing Address - Fax:
Practice Address - Street 1:289 N FIREWEED ST
Practice Address - Street 2:SUITE C
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7540
Practice Address - Country:US
Practice Address - Phone:907-714-4075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-30
Last Update Date:2012-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK937105282NR1301X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No282NR1301XHospitalsGeneral Acute Care HospitalRuralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDG830Medicaid
0004OtherTRICARE
155OtherBLUE CROSS
155OtherBLUE CROSS
155OtherBLUE CROSS
AKK0000ZBBBZMedicare UPIN