Provider Demographics
NPI:1073551131
Name:PRODIGY MEDICAL, LLC
Entity Type:Organization
Organization Name:PRODIGY MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BERENICE
Authorized Official - Middle Name:I
Authorized Official - Last Name:HALPIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-299-3500
Mailing Address - Street 1:4251 HOHE ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7010
Mailing Address - Country:US
Mailing Address - Phone:907-226-3400
Mailing Address - Fax:907-226-3300
Practice Address - Street 1:4251 HOHE ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7010
Practice Address - Country:US
Practice Address - Phone:907-226-3400
Practice Address - Fax:907-226-3300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BP3500X
AK991850332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1598711Medicaid
AK1598711Medicaid
AK6858120001Medicare NSC