Basic Information
| Provider Information | |||||||||
| NPI: | 1932184298 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH EAST ALASKA REGIONAL HEALTH CONSORTIUM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HAINES MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 TONGASS DR | ||||||||
| Address2: | |||||||||
| City: | SITKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998359416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079662411 | ||||||||
| FaxNumber: | 9079668606 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 1ST STREET SOUTH | ||||||||
| Address2: | |||||||||
| City: | HAINES | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077666300 | ||||||||
| FaxNumber: | 9077662675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 07/17/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9074634000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261Q00000X | 70206 | AK | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | DDG226 | 05 | AK | MEDICAID | CL2274 | 05 | AK | MEDICAID | MDG632 | 05 | AK | MEDICAID | MDG630 | 05 | AK | MEDICAID |