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CAH021306-00 PROVIDENCE KODIAK ISLAND MEDICAL CENTER (Active)
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Main Details
Name
PROVIDENCE KODIAK ISLAND MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
Rural
Yes
340B ID
CAH021306-00
Medicare Provider Number
021306
Additional Details
Current Program Status
Active
Registration Date
11/16/2010
Participating Start Date
1/1/2011
Participating Approval Date
11/16/2010
Last Recertification Date
8/13/2024
Contacts
Authorizing Official
Providence Island Medical Center
Lori Michelle Riddle, Administrator
(907) 486-9591 Ext: 9074869550
Primary Contact
Providence Kodiak Island Medical Center
Jason Cole Barkemeyer, Manager
(907) 486-9550
Addresses
Street Address
1915 E REZANOF DRIVE
ATTN PHARMACY
KODIAK, AK 99615
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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2/28/12 -Removed Medicaid # (was PH4793) 2/23/2011- REMOVED MA # (WAS NPI#1629054374 - (AR))
03/28/2012
2/23/2011- REMOVED MA # (WAS NPI#1629054374 - (AR))
02/23/2011
May 2025
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