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General NPI Number Information
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NPI Number | 1831702455
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Entity Type | Organization
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Legal Business Name | FIRESIDE FAMILY MEDICINE LLC
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Dates
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Enumeration Date | 08/24/2020
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Last Update Date | 08/20/2021
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Provider Practice Location Address
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Address Line | 2957 SANTA PATRICIA CT
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City | NORTH POLE
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State | AK
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Zip | 99705-6138
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Country | US
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Telephone | 907-385-0257
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Fax | 907-385-0249
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Provider Business Mailing Address
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Address Line | 2957 SANTA PATRICIA CT
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City | NORTH POLE
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State | AK
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Zip | 99705-6138
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Country | US
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Telephone | 907-385-0257
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Fax | 907-385-0249
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Authorized Official
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Title or Position | OWNER
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Name | DR. BART WORTHINGTON
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Credential | MD
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Telephone | 606-234-5183
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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