NPIMap

Organization Active NPI

The Petersburg Medical Center

  • Home Health Agency
  • Petersburg, AK
National Provider Identifier
1790844033
Registry record updated Oct 8, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Home Health AgencyTaxonomy code 251E00000X
Legal business name
THE PETERSBURG MEDICAL CENTER
Practice address
103 Fram Street
Petersburg, AK 99833-0589
Phone
(907) 772-4291
Fax
(907) 772-3085
NPI assigned
Dec 6, 2006
Last updated
Oct 8, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 8, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Carmen Lantiegne
Title
Office Manager
Phone
(907) 772-4291

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Home Health Registered NurseGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 163WH0200X AK
Home Health Agency 251E00000X Primary

Addresses

Primary practice location

103 Fram Street
Petersburg, AK 99833-0589

Mailing address

103 Fram Street
PO Box 589
Petersburg, AK 99833-0589
Phone (907) 772-4291

Other identifiers 1

IdentifierTypeStateIssuer
HH0057MedicaidAK

Other names 1

  • Petersburg General Hospital Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AK

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060117001187 AK Part A Provider - Home Health Agency 5395730626 Practice locations: Petersburg, AK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1790844033. Details of each certification follow.

Home health agency certification: CCN 027009

Legal name
THE PETERSBURG MEDICAL CENTER
Certification status
Active
Provider type (POS)
Home health agency
Participating since
Jul 21, 1987
Last certification
Nov 9, 2018
Ownership / control type
Non-Profit
Organization structure
OtherNon-profit
Enrollment address
103 Fram St
Petersburg, AK 99833-0589

Other NPIs with the same Medicare PAC ID 3

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

Care Compare: Home health agency

Medicare Care Compare
Listed as
Petersburg Medical Center HomeCCN 027009 · All quality measures
Overall star rating
1.5 of 5
Ownership
Non-Profit
Certified
Jul 21, 1987
Medicare certification status
ActiveFrom the Provider of Services file
Services
Nursing, Home health aide, Physical therapy, Speech pathology, Occupational therapy

National Provider Directory

National Provider Directory
Tax ID family
The Petersburg Medical Center6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

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

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Jacque Kay Grone Individual W-2 Managing Employee Jun 28, 2019
Philip Hofstetter Individual Corporate Director Jul 1, 2018
The Petersburg Medical Center Organization, Petersburg, AK 5% Or Greater Direct Ownership Interest Jan 3, 2013 100%
Jill Dormer Individual Corporate OfficerChief Fiscal Services Oct 1, 2014

Owners & managing parties with NPI records 4

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

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
The Petersburg Medical CenterPetersburg, AK, CCN 02Z304 Hospital 5% Or Greater Direct Ownership Interest (100%) Jan 3, 2013
The Petersburg Medical CenterPetersburg, AK, CCN 025019 Skilled nursing facility Operational/Managerial Control
Direct Ownership Interest (100%)		 Dec 19, 2006
Dec 9, 2006

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 2

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

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 5

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

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165363200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1633651200000",
    "number": "1790844033",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "103 FRAM STREET",
            "address_2": "PO BOX 589",
            "city": "PETERSBURG",
            "state": "AK",
            "postal_code": "998330589",
            "telephone_number": "907-772-4291",
            "fax_number": "907-772-3085"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "103 FRAM STREET",
            "city": "PETERSBURG",
            "state": "AK",
            "postal_code": "998330589",
            "telephone_number": "907-772-4291",
            "fax_number": "907-772-3085"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE PETERSBURG MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-06",
        "last_updated": "2021-10-08",
        "certification_date": "2021-10-08",
        "status": "A",
        "authorized_official_last_name": "LANTIEGNE",
        "authorized_official_first_name": "CARMEN",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "907-772-4291"
    },
    "taxonomies": [
        {
            "code": "163WH0200X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Registered Nurse, Home Health",
            "state": "AK",
            "license": null,
            "primary": false
        },
        {
            "code": "251E00000X",
            "taxonomy_group": "",
            "desc": "Home Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "HH0057",
            "state": "AK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Petersburg General Hospital",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "Petersburg General Hospital",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Petersburg, AK

Sources for this page

Verify at the official NPI Registry.