Provider Demographics
NPI:1770131930
Name:CAPITOL MED
Entity type:Organization
Organization Name:CAPITOL MED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-247-7827
Mailing Address - Street 1:748 MILLER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901
Mailing Address - Country:US
Mailing Address - Phone:201-259-0289
Mailing Address - Fax:973-215-2052
Practice Address - Street 1:25 JEFFERSON WAY
Practice Address - Street 2:SUITE 102B
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5953
Practice Address - Country:US
Practice Address - Phone:907-247-7827
Practice Address - Fax:973-215-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-30
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1700612Medicaid