Provider Demographics
NPI:1437122843
Name:THE PETERSBURG MEDICAL CENTER
Entity Type:Organization
Organization Name:THE PETERSBURG MEDICAL CENTER
Other - Org Name:PETERSBURG GENERAL HOSPITAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOFSTETTER
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:907-772-4291
Mailing Address - Street 1:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:AK
Mailing Address - Zip Code:99833-0589
Mailing Address - Country:US
Mailing Address - Phone:907-772-4291
Mailing Address - Fax:907-772-3085
Practice Address - Street 1:103 FRAM STREET
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833-0589
Practice Address - Country:US
Practice Address - Phone:907-772-4291
Practice Address - Fax:907-772-3085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 261QA0600X
AK282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHS09OPMedicaid
AKHS09IPMedicaid
AK021304Medicare Oscar/Certification