Provider Demographics
NPI:1578794863
Name:CITY OF CRAIG, INC.
Entity Type:Organization
Organization Name:CITY OF CRAIG, INC.
Other - Org Name:CRAIG CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-826-3257
Mailing Address - Street 1:PO BOX 656
Mailing Address - Street 2:
Mailing Address - City:CRAIG
Mailing Address - State:AK
Mailing Address - Zip Code:99921-0656
Mailing Address - Country:US
Mailing Address - Phone:907-826-3257
Mailing Address - Fax:907-826-3259
Practice Address - Street 1:506 3RD ST.
Practice Address - Street 2:
Practice Address - City:CRAIG
Practice Address - State:AK
Practice Address - Zip Code:99921
Practice Address - Country:US
Practice Address - Phone:907-826-3257
Practice Address - Fax:907-826-3259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK710680207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK151640OtherMEDICARE PTAN