1770131930 NPI number — CAPITOL MED

Table of content: (NPI 1770131930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770131930 NPI number — CAPITOL MED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPITOL MED
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:
Provider Other Organization Name Type Code:
6
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:
1770131930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
748 MILLER RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KETCHIKAN
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-259-0289
Provider Business Mailing Address Fax Number:
973-215-2052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 JEFFERSON WAY
Provider Second Line Business Practice Location Address:
SUITE 102B
Provider Business Practice Location Address City Name:
KETCHIKAN
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99901-5953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-247-7827
Provider Business Practice Location Address Fax Number:
973-215-2052
Provider Enumeration Date:
08/30/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER / PHYSICIAN
Authorized Official Telephone Number:
907-247-7827

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1700612 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com