Provider Demographics
NPI:1134277312
Name:HOMER MEDICAL CLINIC, A PROFESSIONAL CORP
Entity type:Organization
Organization Name:HOMER MEDICAL CLINIC, A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HARRISON
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-235-8586
Mailing Address - Street 1:4136 BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7001
Mailing Address - Country:US
Mailing Address - Phone:907-235-8586
Mailing Address - Fax:907-235-6639
Practice Address - Street 1:4136 BARTLETT ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7015
Practice Address - Country:US
Practice Address - Phone:907-235-8586
Practice Address - Fax:907-235-6639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-06
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK279451207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDG 350Medicaid
AK0000WCJGWMedicare ID - Type UnspecifiedGROUP NUMBER