Provider Demographics
NPI:1891874491
Name:BRENT H TAYLOR, MD LLC
Entity Type:Organization
Organization Name:BRENT H TAYLOR, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:H
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-745-9400
Mailing Address - Street 1:2490 S. WOODWORTH LOOP, SUITE 400
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645
Mailing Address - Country:US
Mailing Address - Phone:907-745-9400
Mailing Address - Fax:907-745-9444
Practice Address - Street 1:2490 S. WOODWORTH LOOP, SUITE 400
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645
Practice Address - Country:US
Practice Address - Phone:907-745-9400
Practice Address - Fax:907-745-9444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3517208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKG00861Medicare UPIN
AK15224Medicare ID - Type Unspecified