Provider Demographics
NPI:1912950148
Name:MAT SU VALLEY MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:MAT SU VALLEY MEDICAL CENTER LLC
Other - Org Name:MAT-SU REGIONAL URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR PROVIDER ENROLLMENT CVS
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-465-7042
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:950 E BOGARD RD STE 103
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7184
Practice Address - Country:US
Practice Address - Phone:907-352-2880
Practice Address - Fax:907-352-2885
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAT SU VALLEY MEDICAL CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-18
Last Update Date:2023-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 261QU0200X
AK299454261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020601Medicaid
AK152668Medicare PIN