Provider Demographics
NPI:1073701421
Name:FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:FAMILY MEDICAL CLINIC
Other - Org Name:LAVERN DAVIDHIZAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAVERN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAVIDHIZAR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:907-262-7566
Mailing Address - Street 1:206 W ROCKWELL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7411
Mailing Address - Country:US
Mailing Address - Phone:907-262-7566
Mailing Address - Fax:907-262-0809
Practice Address - Street 1:206 W ROCKWELL AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7411
Practice Address - Country:US
Practice Address - Phone:907-262-7566
Practice Address - Fax:907-262-0809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4221207L00000X, 207LP2900X
AK1454207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1454Medicaid
AKK0000WCHHMMedicare PIN
AKMD1454Medicaid