MEDICARE: MEADOW CREEK HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	423	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376835355
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEADOW CREEK HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	16839 PARK PLACE ST
Second Line	:	SAME
City	:	EAGLE RIVER
State	:	AK
Zip	:	99577-7819
Country	:	US
Telephone Number	:	907-694-3303
Fax Number	:	907-694-4773

Provider Business Practice Location Address
First Line	:	16839 PARK PLACE ST
Second Line	:	SAME
City	:	EAGLE RIVER
State	:	AK
Zip	:	99577-7819
Country	:	US
Telephone Number	:	907-694-3303
Fax Number	:	907-694-4773

Authorized Official
Title or Position	:	OWNER
Name	:	THOMAS A FENGER
Credential	:	PH.D, P.A.
Telephone Number	:	907-694-3303

Provider Enumeration Date	:	05/09/2011
Last Update Date	:	05/09/2011

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