Basic Information
| Provider Information | |||||||||
| NPI: | 1548281215 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GUSTAVUS COMMUNITY CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 399 | ||||||||
| Address2: | |||||||||
| City: | GUSTAVUS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998260399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076973008 | ||||||||
| FaxNumber: | 9076973034 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 DOLLY VARDEN LANE | ||||||||
| Address2: | |||||||||
| City: | GUSTAVUS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076973008 | ||||||||
| FaxNumber: | 9076973034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | KARA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BOARD PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9076973008 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.