Provider Demographics
NPI:1558500694
Name:GLACIER PEDIATRICS, LLC
Entity Type:Organization
Organization Name:GLACIER PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADVANCED NURSE PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:MARYELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:AROVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-586-1542
Mailing Address - Street 1:1600 GLACIER AVE
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1430
Mailing Address - Country:US
Mailing Address - Phone:907-586-1542
Mailing Address - Fax:907-586-1849
Practice Address - Street 1:1600 GLACIER AVE
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1430
Practice Address - Country:US
Practice Address - Phone:907-586-1542
Practice Address - Fax:907-586-1849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK17261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD3544Medicaid
AKMD14482Medicaid
AKNP1539Medicaid
AKMD52881Medicaid