Provider Demographics
NPI:1033277041
Name:HEART OF EAGLE RIVER MEDICAL CLINIC
Entity Type:Organization
Organization Name:HEART OF EAGLE RIVER MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-694-1300
Mailing Address - Street 1:11432 BUSINESS BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7720
Mailing Address - Country:US
Mailing Address - Phone:907-694-1300
Mailing Address - Fax:907-694-1315
Practice Address - Street 1:11432 BUSINESS BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7720
Practice Address - Country:US
Practice Address - Phone:907-694-1300
Practice Address - Fax:907-694-1315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK=========OtherTAX ID
AK5959080001Medicare NSC