# PROVIDENCE KODIAK MEDICAL CENTER

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1306147434
- **Authorized official:** DONALD WAYNE ANDERSON JR. (ASSISTANT SECRETARY OF ENROLLMENTS)
- **Authorized official phone:** (425) 358-9786

## Contact information

- **Practice address:** 1915 E REZANOF DR, KODIAK, AK 99615-6602
- **Practice address phone:** (907) 486-3281
- **Practice address fax:** (907) 481-2497
- **Mailing address:** 1915 E REZANOF DR, KODIAK, AK 99615-6602
- **Mailing address phone:** (907) 486-3281
- **Mailing address fax:** (907) 481-2497

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 311ZA0620X | Adult Care Home Facility | 31478 | AK | Yes |

## Other

- **Enumeration date:** 11/05/2010
- **Last updated:** 05/15/2025