Provider Demographics
NPI:1942323779
Name:GLACIER FAMILY MEDICINE CLINIC LLC
Entity Type:Organization
Organization Name:GLACIER FAMILY MEDICINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:URSEL
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:907-224-8733
Mailing Address - Street 1:11724 SEWARD HWY
Mailing Address - Street 2:STE D
Mailing Address - City:SEWARD
Mailing Address - State:AK
Mailing Address - Zip Code:99664-9714
Mailing Address - Country:US
Mailing Address - Phone:907-224-8733
Mailing Address - Fax:907-224-8734
Practice Address - Street 1:11724 SEWARD HWY
Practice Address - Street 2:STE D
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664-9714
Practice Address - Country:US
Practice Address - Phone:907-224-8733
Practice Address - Fax:907-224-8734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-08
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD22813Medicaid
AK=========OtherBCBS
AK=========OtherOTHER PAR & NONPAR PAYERS
AK=========OtherNORTHWEST NPI SERVICE
AKMD22813Medicaid
AK152151Medicare PIN