NPIMap

Organization Active NPI

Providence Health & Services Washington

Doing business as Providence Kodiak Island Medical Center

  • Emergency Medical Services (Emergency Medicine) Physician
  • Kodiak, AK
National Provider Identifier
1952430902
Registry record updated May 13, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emergency Medical Services (Emergency Medicine) PhysicianTaxonomy code 207PE0004X
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
NPI assigned
Mar 5, 2007
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
Donald Wayne Anderson Jr.
Title
Assistant Secretary of Enrollments
Phone
(425) 358-9786

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Access Hospital 282NC0060X 309115 AK
Emergency Medical Services (Emergency Medicine) Physician 207PE0004X NU Primary
Hospitalist Physician 208M00000X NU

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
MDG191MedicaidAK

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
O20040318000605 AK Part B Supplier - Clinic/Group Practice 5799675120 Receives reassigned benefits from 73 practitioners
Practice locations: Kodiak, AK

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

Practitioners & affiliated clinicians

Practitioners 73

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 73

NPI Registry JSON

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

{
    "created_epoch": "1173052800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747094400000",
    "number": "1952430902",
    "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"
        },
        {
            "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"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES WASHINGTON",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-05",
        "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": false
        },
        {
            "code": "207PE0004X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine, Emergency Medical Services",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "208M00000X",
            "taxonomy_group": "",
            "desc": "Hospitalist",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "MDG191",
            "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

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 13, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.