Provider Demographics
NPI:1649419508
Name:PENINSULA SURGICAL SOLUTIONS, LLC
Entity Type:Organization
Organization Name:PENINSULA SURGICAL SOLUTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-260-7776
Mailing Address - Street 1:254 N BINKLEY ST
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7522
Mailing Address - Country:US
Mailing Address - Phone:907-260-7776
Mailing Address - Fax:907-260-7782
Practice Address - Street 1:254 N BINKLEY ST
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7522
Practice Address - Country:US
Practice Address - Phone:907-260-7776
Practice Address - Fax:907-260-7782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-16
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK119577208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDG150Medicaid