NPIMap

Organization Active NPI

The Petersburg Medical Center

  • Critical Access Hospital
  • Petersburg, AK
National Provider Identifier
1790845204
Registry record updated Nov 19, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Critical Access HospitalTaxonomy code 282NC0060X
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 12, 2006
Last updated
Nov 19, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 19, 2014

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

Authorized official

Name
Elizabeth L Woodyard
Title
Ceo
Phone
(907) 772-4291

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Access Hospital 282NC0060X AK Primary

Addresses

Primary practice location

103 Fram Street
Petersburg, AK 99833-0589

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
HS09SBMedicaidAK

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
O20070914000394 AK Part A Provider - Critical Access Hospital 5395730626 Practice locations: Petersburg, AK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1790845204. Details of each certification follow.

Hospital certification: CCN 02Z304

Legal name
THE PETERSBURG MEDICAL CENTER
Organization structure
OtherNon-profit
Enrollment address
103 Fram St
Petersburg, AK 99833-0589
Hospital Swing-Bed Unit

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

Other NPIs with the same Medicare PAC ID 3

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

National Provider Directory

National Provider Directory
Tax ID family
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 3

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

NameRoleSinceShare
Philip Hofstetter Individual Operational/Managerial ControlCeo Jun 26, 2018 100%
Carmen Lantiegne Individual Operational/Managerial ControlPatient Financial Services Manager Oct 1, 2019
The Petersburg Medical Center Organization, Petersburg, AK 5% Or Greater Direct Ownership Interest Jan 3, 2013 100%

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 025019 Skilled nursing facility Operational/Managerial Control
Direct Ownership Interest (100%)		 Dec 19, 2006
Dec 9, 2006
The Petersburg Medical CenterPetersburg, AK, CCN 027009 Home health agency 5% Or Greater Direct Ownership Interest (100%) Jan 3, 2013

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 17

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.

View all 17

Affiliated clinicians 3

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": "1165881600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1416355200000",
    "number": "1790845204",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "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": "2006-12-12",
        "last_updated": "2014-11-19",
        "status": "A",
        "authorized_official_last_name": "WOODYARD",
        "authorized_official_first_name": "ELIZABETH",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "907-772-4291"
    },
    "taxonomies": [
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": "AK",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "HS09SB",
            "state": "AK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "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.