1295170348 NPI number — POLARIS HOUSE INC.

Table of content: DR. CAROL ANN GAGNON M.D. (NPI 1134272867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295170348 NPI number — POLARIS HOUSE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POLARIS HOUSE INC.
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:
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:
1295170348
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21661
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JUNEAU
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99802-1661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-780-6775
Provider Business Mailing Address Fax Number:
907-780-6774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
434 WILLOUGHBY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JUNEAU
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99801-1724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-780-6775
Provider Business Practice Location Address Fax Number:
907-780-6774
Provider Enumeration Date:
05/02/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
DOROTHY
Authorized Official Middle Name:
LUCILLE
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
907-780-6775

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  914750 , 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)