1811135247 NPI number — R LYNN CARLSON MD PC MEDICENTER

Table of content: (NPI 1811135247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811135247 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:
1811135247
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10543 KENAI SPUR HWY
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:
99611-7812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-283-9118
Provider Business Mailing Address Fax Number:
907-283-5341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10543 KENAI SPUR HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENAI
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99611-7812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-283-9118
Provider Business Practice Location Address Fax Number:
907-283-5341
Provider Enumeration Date:
01/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CARLSON
Authorized Official First Name:
R LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PHYSICIAN
Authorized Official Telephone Number:
907-283-9118

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MPG0152 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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