Basic Information
| Provider Information | |||||||||
| NPI: | 1548723083 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIRD | ||||||||
| FirstName: | TASHA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 310 | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996580310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074383500 | ||||||||
| FaxNumber: | 9074383540 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 HOSPITAL ROAD | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074383500 | ||||||||
| FaxNumber: | 9074383540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2019 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1020986 | 05 | AK | MEDICAID |