Provider Demographics
NPI:1225263445
Name:CENTRAL PENINSULA GENERAL HOSPITAL
Entity Type:Organization
Organization Name:CENTRAL PENINSULA GENERAL HOSPITAL
Other - Org Name:CENTRAL PENINSULA PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-714-4718
Mailing Address - Street 1:289 N. FIREWEED STREET
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:907-714-4045
Mailing Address - Fax:
Practice Address - Street 1:289 N. FIREWEED STREET
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:907-714-4045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK928993208000000X, 282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK0004OtherTRIWEST
AK155OtherBLUE CROSS
AK=========OtherAETNA