Provider Demographics
NPI:1952310369
Name:PENINSULA SURGICAL CLINIC PC
Entity Type:Organization
Organization Name:PENINSULA SURGICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:M
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:BOLING
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:907-235-3225
Mailing Address - Street 1:35477 KENAI SPUR HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7625
Mailing Address - Country:US
Mailing Address - Phone:907-262-6800
Mailing Address - Fax:907-262-9276
Practice Address - Street 1:203 W PIONEER AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7527
Practice Address - Country:US
Practice Address - Phone:907-262-6800
Practice Address - Fax:907-262-9276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3945208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMPG0405Medicaid
AK151829Medicare PIN
AKMPG0405Medicaid