Provider Demographics
NPI:1093968372
Name:SOUTH PENINSULA HOSPITAL, INC
Entity Type:Organization
Organization Name:SOUTH PENINSULA HOSPITAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-235-0241
Mailing Address - Street 1:4300 BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7005
Mailing Address - Country:US
Mailing Address - Phone:907-235-8101
Mailing Address - Fax:907-235-0253
Practice Address - Street 1:4300 BARTLETT ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7005
Practice Address - Country:US
Practice Address - Phone:907-235-8101
Practice Address - Fax:907-235-0253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK192072275N00000X, 282NC0060X
282N00000X, 313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
No282N00000XHospitalsGeneral Acute Care Hospital
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1005654Medicaid
AK1582637Medicaid
AK1687514Medicaid
AK1005653Medicaid
AK1020634Medicaid
AK1582664Medicaid
AK1687518Medicaid
AK1701931Medicaid