Provider Demographics
NPI:1003967753
Name:SOUTH CENTRAL FAMILY PRACTICE CLINIC PC
Entity Type:Organization
Organization Name:SOUTH CENTRAL FAMILY PRACTICE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAILON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-260-7784
Mailing Address - Street 1:PO BOX 1249
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-1249
Mailing Address - Country:US
Mailing Address - Phone:907-260-7784
Mailing Address - Fax:907-260-7738
Practice Address - Street 1:161 N BINKLEY ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:907-260-7784
Practice Address - Fax:907-260-7738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK901044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK610985200OtherOWCP FEDERAL WORKERS COMP
AK610985200OtherOWCP FEDERAL BLACK LUNG
AKGJ520OtherPACIFIC SOURCE HEALTH