Provider Demographics
NPI:1972666345
Name:PETERSBURG MEDICAL CENTER
Entity Type:Organization
Organization Name:PETERSBURG MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRINGHURST
Authorized Official - Suffix:
Authorized Official - Credentials:
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:907-772-4299
Practice Address - Fax:907-772-9273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK0000ZGBJVMedicare ID - Type UnspecifiedPHYSICIAN GROUP PRACTICE