Provider Demographics
NPI:1285661959
Name:PENINSULA INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:PENINSULA INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CORPORATE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-262-8597
Mailing Address - Street 1:247 N FIREWEED
Mailing Address - Street 2:STE A
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669
Mailing Address - Country:US
Mailing Address - Phone:907-262-8597
Mailing Address - Fax:907-262-6516
Practice Address - Street 1:247 N FIREWEED ST
Practice Address - Street 2:STE A
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7540
Practice Address - Country:US
Practice Address - Phone:907-262-8597
Practice Address - Fax:907-262-6516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDG848Medicaid
AKMDG848Medicaid
AKMDG848Medicaid
AKCE1671Medicare PIN
AKK0000WCVBSMedicare PIN