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
StateLicense IDTaxonomies
207PE0004X, 207X00000X, 208600000X, 261QM1300X, 282NC0060X
AK192072207X00000X, 2085R0202X, 2085U0001X, 208600000X, 275N00000X, 282N00000X, 282NR1301X, 282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NR1301XHospitalsGeneral Acute Care HospitalRuralGroup - Multi-Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical AccessGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No275N00000XHospital UnitsMedicare Defined Swing Bed UnitGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
No282E00000XHospitalsLong Term Care HospitalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1005186Medicaid
AK1582637Medicaid
AK1687518Medicaid
AK1020634Medicaid
AK1028527Medicaid
AK1582664Medicaid
AK1701931Medicaid
AK1005654Medicaid
AK1005653Medicaid
AK1687514Medicaid
AKMD22673Medicaid
AKMD10151Medicaid
AKMD36582Medicaid
AKMD15931Medicaid
AKMD2143Medicaid
AKHS15OPMedicaid
AKMDG142Medicaid
AKMD2143Medicaid
AKMD26463Medicaid
AKMD15931Medicaid
AKMD19253Medicaid