Basic Information
Provider Information | |||||||||
NPI: | 1821041666 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SALARD | ||||||||
FirstName: | GREG | ||||||||
MiddleName: | ALAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1231 | ||||||||
Address2: |   | ||||||||
City: | WRANGELL | ||||||||
State: | AK | ||||||||
PostalCode: | 99929 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9078744700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 320 BENNETT STREET | ||||||||
Address2: |   | ||||||||
City: | WRANGELL | ||||||||
State: | AK | ||||||||
PostalCode: | 99929 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9078744700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 12/26/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E-4681 | AR | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 026081 | LA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 5052 | AK | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 05413 | 05 | LA |   | MEDICAID | 200092570A | 05 | OK |   | MEDICAID | 161466001 | 05 | AR |   | MEDICAID |