Basic Information
| Provider Information | |||||||||
| NPI: | 1316015480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALASKA MEDICAL CLINICS, LLC | ||||||||
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| OtherOrganizationName: | WASILLA MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 E PARKS HWY | ||||||||
| Address2: | #200 | ||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996547352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073736055 | ||||||||
| FaxNumber: | 9073736077 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 E PARKS HWY | ||||||||
| Address2: | #200 | ||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996547352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073736055 | ||||||||
| FaxNumber: | 9073736077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 04/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | MACLEAN | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | LOUISE | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9073417714 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MDG016 | 05 | AK | MEDICAID | MDG017 | 05 | AK | MEDICAID |