Provider Demographics
| NPI: | 1679566269 |
|---|---|
| Name: | SOUTH PENINSULA HOSPITAL, INC. |
| Entity Type: | Organization |
| Organization Name: | SOUTH PENINSULA HOSPITAL, INC. |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CHIEF EXECUTIVE OFFICER |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | RYAN |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | SMITH |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 907-235-0241 |
| Mailing Address - Street 1: | 4300 BARTLETT STREET |
| Mailing Address - Street 2: | |
| Mailing Address - City: | HOMER |
| Mailing Address - State: | AK |
| Mailing Address - Zip Code: | 99603-7005 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 907-235-8101 |
| Mailing Address - Fax: | 907-235-0253 |
| Practice Address - Street 1: | 4300 BARTLETT STREET |
| Practice Address - Street 2: | |
| Practice Address - City: | HOMER |
| Practice Address - State: | AK |
| Practice Address - Zip Code: | 99603-7005 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 907-235-8101 |
| Practice Address - Fax: | 907-235-0253 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2005-08-29 |
| Last Update Date: | 2020-02-07 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 207PE0004X, 207X00000X, 208600000X, 261QM1300X, 282NC0060X | ||
| AK | 192072 | 207X00000X, 2085R0202X, 2085U0001X, 208600000X, 275N00000X, 282N00000X, 282NR1301X, 282E00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 282NR1301X | Hospitals | General Acute Care Hospital | Rural | Group - Multi-Specialty |
| No | 207PE0004X | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | Group - Multi-Specialty |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
| Yes | 282NC0060X | Hospitals | General Acute Care Hospital | Critical Access | Group - Multi-Specialty |
| No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
| No | 2085U0001X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | Group - Multi-Specialty |
| No | 275N00000X | Hospital Units | Medicare Defined Swing Bed Unit | Group - Multi-Specialty | |
| No | 282N00000X | Hospitals | General Acute Care Hospital | Group - Multi-Specialty | |
| No | 282E00000X | Hospitals | Long Term Care Hospital | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| AK | 1005186 | Medicaid | |
| AK | 1582637 | Medicaid | |
| AK | 1687518 | Medicaid | |
| AK | 1020634 | Medicaid | |
| AK | 1028527 | Medicaid | |
| AK | 1582664 | Medicaid | |
| AK | 1701931 | Medicaid | |
| AK | 1005654 | Medicaid | |
| AK | 1005653 | Medicaid | |
| AK | 1687514 | Medicaid | |
| AK | MD22673 | Medicaid | |
| AK | MD10151 | Medicaid | |
| AK | MD36582 | Medicaid | |
| AK | MD15931 | Medicaid | |
| AK | MD2143 | Medicaid | |
| AK | HS15OP | Medicaid | |
| AK | MDG142 | Medicaid | |
| AK | MD2143 | Medicaid | |
| AK | MD26463 | Medicaid | |
| AK | MD15931 | Medicaid | |
| AK | MD19253 | Medicaid |
