Provider Demographics
NPI:1215385794
Name:R LYNN CARLSON MD PC MEDICENTER
Entity Type:Organization
Organization Name:R LYNN CARLSON MD PC MEDICENTER
Other - Org Name:MEDICENTER NORTH RHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:HURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:BM, PFS
Authorized Official - Phone:360-771-7458
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-0240
Mailing Address - Country:US
Mailing Address - Phone:907-283-9118
Mailing Address - Fax:
Practice Address - Street 1:43783 KENAI SPUR HWY
Practice Address - Street 2:
Practice Address - City:NIKISKI
Practice Address - State:AK
Practice Address - Zip Code:99611-9708
Practice Address - Country:US
Practice Address - Phone:907-283-9116
Practice Address - Fax:907-283-9122
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:R LYNN CARLSON MD PC MEDICENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-25
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPADA895363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1012124Medicaid
AK1020379Medicaid
AK1625263Medicaid
AK1008129Medicaid
AK1010950Medicaid
AK1584686Medicaid