Healthcare Provider Details

I. General information

NPI: 1740571645
Provider Name (Legal Business Name): GLACIER GENERAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 04/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3419 AIRPORT WAY STE B
FAIRBANKS AK
99709-4761
US

IV. Provider business mailing address

3419 AIRPORT WAY STE B
FAIRBANKS AK
99709-4761
US

V. Phone/Fax

Practice location:
  • Phone: 907-374-8914
  • Fax: 907-374-8915
Mailing address:
  • Phone: 907-374-8914
  • Fax: 907-374-8915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: SLYVIA MCCORMICK
Title or Position: MEMBER
Credential:
Phone: 907-374-8914