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General NPI Number Information
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NPI Number | 1740571645
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Entity Type | Organization
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Legal Business Name | GLACIER GENERAL MEDICINE, LLC
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Dates
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Enumeration Date | 04/26/2011
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Last Update Date | 04/26/2011
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Provider Practice Location Address
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Address Line | 3419 AIRPORT WAY STE B
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City | FAIRBANKS
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State | AK
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Zip | 99709-4761
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Country | US
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Telephone | 907-374-8914
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Fax | 907-374-8915
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Provider Business Mailing Address
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Address Line | 3419 AIRPORT WAY STE B
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City | FAIRBANKS
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State | AK
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Zip | 99709-4761
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Country | US
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Telephone | 907-374-8914
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Fax | 907-374-8915
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Authorized Official
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Title or Position | MEMBER
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Name | SLYVIA MCCORMICK
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Credential |
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Telephone | 907-374-8914
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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