Provider Demographics
NPI:1699004853
Name:HERITAGE FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:HERITAGE FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:SAHLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-982-5300
Mailing Address - Street 1:4931 E MAYFLOWER LN
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7759
Mailing Address - Country:US
Mailing Address - Phone:907-376-5337
Mailing Address - Fax:
Practice Address - Street 1:4961 E MAYFLOWER LN
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7708
Practice Address - Country:US
Practice Address - Phone:907-376-5337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-17
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6506207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0506Medicaid
AKMPG0164Medicaid
AKK162794Medicare PIN