Provider Demographics
NPI:1376835355
Name:MEADOW CREEK HEALTHCARE LLC
Entity Type:Organization
Organization Name:MEADOW CREEK HEALTHCARE LLC
Other - Org Name:MEADOW CREEK DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:FENGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PA
Authorized Official - Phone:907-694-3303
Mailing Address - Street 1:16839 PARK PLACE ST
Mailing Address - Street 2:SAME
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7819
Mailing Address - Country:US
Mailing Address - Phone:907-694-3303
Mailing Address - Fax:907-694-4773
Practice Address - Street 1:16839 PARK PLACE ST
Practice Address - Street 2:SAME
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7819
Practice Address - Country:US
Practice Address - Phone:907-694-3303
Practice Address - Fax:907-694-4773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK423363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMPG0123Medicaid