Provider Demographics
NPI:1083657712
Name:GIRDWOOD CLINIC, INC.
Entity Type:Organization
Organization Name:GIRDWOOD CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DORIUS
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:907-783-1355
Mailing Address - Street 1:PO BOX 1130
Mailing Address - Street 2:
Mailing Address - City:GIRDWOOD
Mailing Address - State:AK
Mailing Address - Zip Code:99587-1130
Mailing Address - Country:US
Mailing Address - Phone:907-783-1355
Mailing Address - Fax:907-783-1357
Practice Address - Street 1:LOT 17 BLOCK 1
Practice Address - Street 2:NEW GIRDWOOD TOWN SITE
Practice Address - City:GIRDWOOD
Practice Address - State:AK
Practice Address - Zip Code:99587
Practice Address - Country:US
Practice Address - Phone:907-783-1355
Practice Address - Fax:907-783-1357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMS5623Medicaid
AK4902170001Medicare ID - Type UnspecifiedMEDICARE DME-CIGNA
AKMS5623Medicaid