Provider Demographics
NPI:1235319450
Name:EAGLE RIVER PRIMARY CARE
Entity Type:Organization
Organization Name:EAGLE RIVER PRIMARY CARE
Other - Org Name:EAGLE RIVER PRIMARY CARE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:J
Authorized Official - Last Name:OXFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:907-694-0770
Mailing Address - Street 1:11462 BUSINESS BLVD
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7721
Mailing Address - Country:US
Mailing Address - Phone:907-694-0770
Mailing Address - Fax:907-694-1378
Practice Address - Street 1:11462 BUSINESS BLVD
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7721
Practice Address - Country:US
Practice Address - Phone:907-694-0770
Practice Address - Fax:907-694-1378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPA448363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1407920085OtherINDIVIDUAL NPI
AKMD57671Medicaid
AKMD42453Medicaid
AK$$$$$$$$$OtherINDIVIDUAL SSN
AK1326187055OtherINDIVIDUAL NPI
AK=========OtherTIN
AKMD57671Medicaid
AKK152856Medicare PIN
AK1326187055OtherINDIVIDUAL NPI
AKQ01631Medicare UPIN
AKK152858Medicare PIN
AKE31829Medicare UPIN