Provider Demographics
NPI:1659580967
Name:SOUTHCENTRAL FOUNDATION MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTHCENTRAL FOUNDATION MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-729-1905
Mailing Address - Street 1:4155 TUDOR CENTRE DR STE 103
Mailing Address - Street 2:ATTN SHERRY REEDY
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5912
Mailing Address - Country:US
Mailing Address - Phone:907-729-3971
Mailing Address - Fax:907-729-1572
Practice Address - Street 1:4155 TUDOR CENTRE DR STE 103
Practice Address - Street 2:ATTN SHERRY REEDY
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5912
Practice Address - Country:US
Practice Address - Phone:907-729-3971
Practice Address - Fax:907-729-1572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK20467332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMS4320Medicaid
AKMS4320Medicaid