1215385794 NPI number — R LYNN CARLSON MD PC MEDICENTER

Table of content: (NPI 1215385794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215385794 NPI number — R LYNN CARLSON MD PC MEDICENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
R LYNN CARLSON MD PC MEDICENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215385794
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENAI
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99611-0240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-283-9118
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43783 KENAI SPUR HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NIKISKI
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99611-9708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-283-9116
Provider Business Practice Location Address Fax Number:
907-283-9122
Provider Enumeration Date:
05/25/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HURLEY
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
360-771-7458

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PADA895 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1012124 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1020379 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1625263 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1008129 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1010950 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1584686 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com