Provider Demographics
NPI:1144392317
Name:MEDICAL PARK FAMILY CARE, INC
Entity Type:Organization
Organization Name:MEDICAL PARK FAMILY CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-257-8121
Mailing Address - Street 1:2211 E NORTHERN LIGHTS BLVD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-279-8486
Mailing Address - Fax:907-677-5614
Practice Address - Street 1:2211 E NORTHERN LIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4103
Practice Address - Country:US
Practice Address - Phone:907-257-8486
Practice Address - Fax:907-677-5614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK02D0864632OtherCLIA
AKKOOOOWCHKZOtherMEDICARE
AK1004348Medicaid