NPIMap

Organization Active NPI

Providence Health & Services Washington

Doing business as Providence Kodiak Island Medical Center

  • Skilled Nursing Facility
  • Kodiak, AK
National Provider Identifier
1790889400
Registry record updated May 13, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
309115 Issued in AK
Legal business name
PROVIDENCE HEALTH & SERVICES WASHINGTON
Doing business as
Providence Kodiak Island Medical Center
Practice address
1915 E Rezanof Dr
Kodiak, AK 99615-6602
Phone
(907) 486-3281
Fax
(907) 486-9546
NPI assigned
Sep 12, 2006
Last updated
May 13, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 13, 2025

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 309115 AK Primary

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 1

IdentifierTypeStateIssuer
HS10SBMedicaidAK

Other names 1

  • Providence Kodiak Island Medical Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070914000357 AK Part A Provider - Critical Access Hospital 5799675120 Practice locations: Kodiak, AK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1790889400. Details of each certification follow.

Hospital certification: CCN 02Z306

Legal name
PROVIDENCE HEALTH & SERVICES WASHINGTON
Doing business as
PROVIDENCE KODIAK ISLAND MEDICAL CENTER
Organization structure
CorporationNon-profit
Incorporated
Jan 28, 1859 in WA
Enrollment address
1915 E Rezanof Dr
Kodiak, AK 99615-6602

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

Other NPIs with the same Medicare PAC ID 2

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

National Provider Directory

National Provider Directory
Tax ID family
Providence Kodiak Medical Center8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

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

Ownership & related parties

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 DirectorBoard of Directors Jul 1, 2016
Richard S Blair Individual Corporate DirectorBaord of Directors Jul 1, 2016
Marvin O'Quinn Individual Corporate DirectorBoard Member Jan 1, 2024
Linda Buck Individual Corporate DirectorBoard Member Jan 1, 2025
Providence Health & Services - Washington Organization, Renton, WA Non-profit 5% Or Greater Direct Ownership Interest Apr 21, 1997 100%
Mary E Lyons Individual Corporate DirectorBoard of Directors Jul 1, 2016
Benjamin Carver Individual W-2 Managing EmployeeFinancial Executive May 16, 2025
John Loomis Individual W-2 Managing EmployeeAd; Nov 10, 2025
James Travis Individual W-2 Managing EmployeeFinancial Executive Mar 30, 2026
Phyllis M Hughes Individual Corporate DirectorBoard of Directors Jul 1, 2016
Rogelio Riojas Individual Corporate DirectorBoard Member Jan 1, 2025
James Martin Individual Corporate OfficerAssistant Treasurer Jan 13, 2023
Charles Wallace Sorenson Individual Corporate DirectorBoard Member Jan 1, 2019
Donald Wayne Anderson Individual Corporate OfficerAssistant Secretary of Enrollments Jan 1, 2017
Gregory David Hoffman Individual Corporate OfficerCfo/Treasurer Jan 1, 2025
Isiaah D Crawford Individual Corporate DirectorDirector Feb 1, 2012
Donna Markham Individual Corporate DirectorBoard Member Jan 1, 2024
Michael W Murphy Individual Corporate DirectorBoard of Directors Jan 1, 2020
Providence Health & Services Organization, Renton, WA Non-profit Other Jul 1, 2016
Mary Beth Kingston Individual Corporate DirectorBoard of Directors Sep 1, 2022
Eric D Sprunk Individual Corporate DirectorBoard of Directors Jan 1, 2022
Anna R Newsom Individual Corporate OfficerCorporate Secretary May 13, 2022
Darryl Elmouchi Individual Corporate OfficerPresident/Ceo Apr 1, 2025
Karin Dufault Individual Corporate DirectorBoard Member Jan 1, 2025
Providence St. Joseph Health Organization, Renton, WA Non-profit Other Jul 1, 2016

Owners & managing parties with NPI records 2

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

Facilities with the same owner 139

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

  • Alaska Specialty Hospital, LLC

    dba Providence St Elias Rehabilitation Unit

    • Rehabilitation Hospital Unit
    • Anchorage, AK
    • NPI 1861045445

    Providence Health & Services - Washington

    CMS ownership
  • Alaska Specialty Hospital, LLC
    • Long Term Care Hospital
    • Anchorage, AK
    • NPI 1912965021

    Providence Health & Services - Washington

    CMS ownership
  • City of Seward

    dba Providence Seward Medical Center

    • Critical Access Hospital
    • Seward, AK
    • NPI 1396858155

    Providence Health & Services - Washington

    CMS ownership
  • City of Seward

    dba Providence Seward Medical Center

    • Medicare Defined Swing Bed Hospital Unit
    • Seward, AK
    • NPI 1649340217

    Providence Health & Services - Washington

    CMS ownership
  • City of Seward

    dba Providence Seward Mountain Haven

    • Skilled Nursing Facility
    • Seward, AK
    • NPI 1821102757

    Providence Health & Services - Washington

    CMS ownership
  • City of Valdez

    dba Providence Valdez Medical Center

    • Medicare Defined Swing Bed Hospital Unit
    • Valdez, AK
    • NPI 1336247824

    Providence Health & Services - Washington

    CMS ownership
  • City of Valdez

    dba Providence Valdez Medical Center

    • Critical Access Hospital
    • Valdez, AK
    • NPI 1750485488

    Providence Health & Services - Washington

    CMS ownership
  • City of Valdez

    dba Providence Valdez Medical Center

    • Skilled Nursing Facility
    • Valdez, AK
    • NPI 1790715928

    Providence Health & Services - Washington

    CMS ownership
  • CP Ak HH, LLC

    dba Providence at Home with Compassus Home Health, Anchorage

    • Home Health Agency
    • Anchorage, AK
    • NPI 1134941156

    Providence Health & Services - Washington

    CMS ownership
  • CP Ak Hospice, LLC

    dba Providence at Home with Compassus Hospice Care, Anchorage

    • Community Based Hospice Care Agency
    • Anchorage, AK
    • NPI 1114749132

    Providence Health & Services - Washington

    CMS ownership
  • Providence Health & Services Washington

    dba Providence Kodiak Island Medical Center

    • Critical Access Hospital
    • Kodiak, AK
    • NPI 1013905660

    Providence Health & Services - Washington

    CMS ownership
  • Providence Health & Services Washington

    dba Providence Alaska Medical Center

    • General Acute Care Hospital
    • Anchorage, AK
    • NPI 1053363119

    Providence Health & Services - Washington

    CMS ownership
View all 139

Practitioners & affiliated clinicians

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": "1158019200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747094400000",
    "number": "1790889400",
    "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": "2006-09-12",
        "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_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "AK",
            "license": "309115",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "HS10SB",
            "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

Sources for this page

Verify at the official NPI Registry.