Provider Demographics
NPI:1811135247
Name:R LYNN CARLSON MD PC MEDICENTER
Entity type:Organization
Organization Name:R LYNN CARLSON MD PC MEDICENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:R LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-283-9118
Mailing Address - Street 1:10543 KENAI SPUR HWY
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7812
Mailing Address - Country:US
Mailing Address - Phone:907-283-9118
Mailing Address - Fax:907-283-5341
Practice Address - Street 1:10543 KENAI SPUR HWY
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7812
Practice Address - Country:US
Practice Address - Phone:907-283-9118
Practice Address - Fax:907-283-5341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMPG0152Medicaid