1194261594 NPI number — SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM

Table of content: (NPI 1194261594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194261594 NPI number — SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SEARHC FRONT STREET CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194261594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 CHANNEL DRIVE STE 300
Provider Second Line Business Mailing Address:
ATTN: PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
JUNEAU
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-463-4000
Provider Business Mailing Address Fax Number:
907-463-1510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 FRONT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JUNEAU
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-586-4230
Provider Business Practice Location Address Fax Number:
907-586-4237
Provider Enumeration Date:
01/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
907-463-4000

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  70206 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1662851 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1684455 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 70206 . This is a "BUSINESS LICENSE" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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