Provider Demographics
NPI:1114232592
Name:CHARLES G. PERKINS
Entity Type:Organization
Organization Name:CHARLES G. PERKINS
Other - Org Name:PENINSULA NEUROLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:G
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-262-6557
Mailing Address - Street 1:167 WAREHOUSE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669
Mailing Address - Country:US
Mailing Address - Phone:907-262-6557
Mailing Address - Fax:907-262-6559
Practice Address - Street 1:167 WAREHOUSE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:907-262-6557
Practice Address - Fax:907-262-6559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2407261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKM2407Medicaid
AKM2407Medicaid