Provider Demographics
NPI:1497336226
Name:MIDNIGHT SUN GENL MEDICINE CLINIC
Entity Type:Organization
Organization Name:MIDNIGHT SUN GENL MEDICINE CLINIC
Other - Org Name:MIDNIGHT SUN CLINIC AND MEDICAL SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-775-6780
Mailing Address - Street 1:91-3633 KAULUAKOKO ST UNIT 406
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-5867
Mailing Address - Country:US
Mailing Address - Phone:907-775-6780
Mailing Address - Fax:808-312-4582
Practice Address - Street 1:91-3633 KAULUAKOKO ST UNIT 406
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-5867
Practice Address - Country:US
Practice Address - Phone:907-775-6780
Practice Address - Fax:808-312-4582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-14
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty