Provider Demographics
NPI:1861637555
Name:RAINBOW MEDICAL CLINIC
Entity Type:Organization
Organization Name:RAINBOW MEDICAL CLINIC
Other - Org Name:STEPHEN SHORTRIDGE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:SHORTRIGE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:907-892-3350
Mailing Address - Street 1:PO BOX 520562
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:AK
Mailing Address - Zip Code:99652-0562
Mailing Address - Country:US
Mailing Address - Phone:907-892-3350
Mailing Address - Fax:907-892-3351
Practice Address - Street 1:10927 WEST PARKS HWY.
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:AK
Practice Address - Zip Code:99652-0562
Practice Address - Country:US
Practice Address - Phone:907-892-3350
Practice Address - Fax:907-892-3351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1700994118OtherNPI
S31230Medicare UPIN