Provider Demographics
NPI:1740571645
Name:GLACIER GENERAL MEDICINE, LLC
Entity Type:Organization
Organization Name:GLACIER GENERAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SLYVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-374-8914
Mailing Address - Street 1:3419 AIRPORT WAY STE B
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4761
Mailing Address - Country:US
Mailing Address - Phone:907-374-8914
Mailing Address - Fax:907-374-8915
Practice Address - Street 1:3419 AIRPORT WAY STE B
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4761
Practice Address - Country:US
Practice Address - Phone:907-374-8914
Practice Address - Fax:907-374-8915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty