Healthcare Provider Details

I. General information

NPI: 1174890826
Provider Name (Legal Business Name): COLIN MEGLITSCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2011
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 TAKOTNA AVE
MCGRATH AK
99627
US

IV. Provider business mailing address

4201 TUDOR CENTRE DR SUITE 320
ANCHORAGE AK
99508-5904
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-7000
  • Fax:
Mailing address:
  • Phone: 907-729-6350
  • Fax: 907-729-8607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierMDH0158
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: