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Providence Health & Services Washington

Organization Active NPI Critical Access Hospital · Kodiak, AK

NPI 1013905660 · NPPES record last updated May 13, 2025

Key facts

NPI
1013905660
Entity type
Organization (NPI type 2)
Primary specialty
Critical Access Hospital 282NC0060X
License
309115 (AK)
Legal business name
PROVIDENCE HEALTH & SERVICES WASHINGTON
Practice address
1915 E Rezanof Dr
Kodiak, AK 99615-6602
Phone
(907) 486-3281
Fax
(907) 486-9546
NPI assigned
Oct 7, 2005
Organization subpart
No

Authorized official

Name
Donald Wayne Anderson Jr.
Title
Assistant Secretary of Enrollments
Phone
(425) 358-9786

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Corporate family (same tax ID) 7

Organizations that report the same tax identification number in the National Provider Directory.

Facilities connected through Provider of Services related, parent or unit certification numbers.

Facilities with the same owner 139

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 139

Practitioners 65

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 65

Affiliated clinicians 106

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 106

Medicare Care Compare: Hospital

Listed as
Providence Kodiak Island Medical Ctr CCN 021306
Type
Critical Access Hospitals
Ownership
Voluntary non-profit - Church
Medicare certification status
Active (Provider of Services file)
Emergency services
Yes

Source: Medicare Care Compare.

Medicare participation

Medicare fee-for-service enrollment
Enrolled in AK

Hospital certification: CCN 021306

Legal name
PROVIDENCE HEALTH & SERVICES WASHINGTON
Doing business as
PROVIDENCE KODIAK ISLAND MEDICAL CENTER
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Jun 1, 2003
Last certification
Jun 3, 2016
Beds
25
Ownership / control type
Church
Organization structure
Corporation · Non-profit
Incorporated
Jan 28, 1859 in WA
Enrollment address
1915 E Rezanof Dr
Kodiak, AK 99615-6602

All disclosed owners & managing parties 25

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Diane L Hejna
Individual 		Corporate Director
Board Member		 Jul 1, 2016
Richard S Blair
Individual 		Corporate Director
Board Member - Chairman		 Jul 1, 2016
Marvin O'Quinn
Individual 		Corporate Director
Director		 Jan 1, 2024
Linda Buck
Individual 		Corporate Director
Board Member		 Jan 1, 2025
Providence Health & Services - Washington
Organization · Renton, WA
Non-profit 		5% Or Greater Direct Ownership Interest Apr 21, 1997 100%
Operational/Managerial Control Apr 21, 1997
Mary E Lyons
Individual 		Corporate Director
Board Member		 Jul 1, 2016
Benjamin Carver
Individual 		W-2 Managing Employee
Financial Executive		 May 16, 2025
John Loomis
Individual 		W-2 Managing Employee
Ad;		 Nov 10, 2025
James Travis
Individual 		W-2 Managing Employee
Financial Executive		 Mar 30, 2026
Phyllis M Hughes
Individual 		Corporate Director
Board Member		 Jan 1, 2014
Rogelio Riojas
Individual 		Corporate Director
Board Member		 Jan 1, 2025
James Martin
Individual 		Corporate Officer
Assistant Treasurer		 Jan 13, 2023
Charles Wallace Sorenson
Individual 		Corporate Director
Board Member		 Jan 1, 2019
Donald Wayne Anderson
Individual 		Corporate Officer
Assistant Secretary of Enrollments		 Jan 1, 2025
Gregory David Hoffman
Individual 		Corporate Officer
Cfo/Treasurer		 Oct 1, 2020
Isiaah D Crawford
Individual 		Corporate Director
Board Member		 Feb 1, 2012
Donna Markham
Individual 		Corporate Director
Director		 Jan 1, 2024
Michael W Murphy
Individual 		Corporate Director
Board of Directors		 Jan 1, 2020
Providence Health & Services
Organization · Renton, WA
Non-profit 		Other Jul 1, 2016
Mary Beth Kingston
Individual 		Corporate Director
Board of Directors		 Sep 1, 2022
Eric D Sprunk
Individual 		Corporate Director
Board of Directors		 Jan 1, 2022
Anna R Newsom
Individual 		Corporate Officer
Corporate Secretary		 May 13, 2022
Darryl Elmouchi
Individual 		Corporate Officer
President/Ceo		 Apr 1, 2025
Karin Dufault
Individual 		Corporate Director
Board Member		 Jan 1, 2025
Providence St. Joseph Health
Organization · Renton, WA
Non-profit 		Other Jul 1, 2016

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20041221000920 AK Part a Provider - Critical Access Hospital 5799675120 Receives reassigned benefits from 55 practitioners
Practice locations: Kodiak, AK

National Provider Directory

Tax ID family
Providence Health Services -Washington (8 organizations share this tax ID)

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Access Hospital 282NC0060X 309115 AK Yes

Addresses

Primary practice location

1915 E Rezanof Dr
Kodiak, AK 99615-6602

Mailing address

PO Box 3706
Portland, OR 97208-3706
Phone (907) 486-3281

Other identifiers

IdentifierTypeStateIssuer
HS10MedicaidAK

Other names

  • Providence Kodiak Island Medical Center Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on May 13, 2025.

{
    "created_epoch": "1128643200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747094400000",
    "number": "1013905660",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3706",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083706",
            "telephone_number": "907-486-3281",
            "fax_number": "907-486-9546"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1915 E REZANOF DR",
            "city": "KODIAK",
            "state": "AK",
            "postal_code": "996156602",
            "telephone_number": "907-486-3281",
            "fax_number": "907-486-9546"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES WASHINGTON",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-07",
        "last_updated": "2025-05-13",
        "certification_date": "2025-05-13",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY OF ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": "AK",
            "license": "309115",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "HS10",
            "state": "AK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Providence Kodiak Island Medical Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Providence Kodiak Island Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kodiak, AK

All providers in Kodiak, AK · Critical Access Hospital in Alaska

Sources for this page

Verify at the official NPI Registry.