WILD IRIS LLC (WILD IRIS FAMILY MEDICINE AND MATERNITY CARE) - NPI NUMBER 1003244211

Summary

Provider Name: WILD IRIS LLC (WILD IRIS FAMILY MEDICINE AND MATERNITY CARE)

NPI Number: 1003244211

Clasification: Family Medicine (207Q00000X)

Address:
851 E WESTPOINT DR
SUITE 207
WASILLA, AK
ZIP 99654

Phone Number: (907) 373-9463



Detailed Information

WILD IRIS LLC is a family physician in Wasilla, AK. The provider is family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity. The assigned NPI number for this provider is 1003244211 and is registered as an organization entity type and is a single specialty group.
The provider Is Doing Business As Wild Iris Family Medicine And Maternity Care.

The provider's business address is:

851 E WESTPOINT DR
SUITE 207
WASILLA, AK
ZIP 99654-183
Phone: (907) 373-9463

The provider's authorized official is Lisa Harrison .
The authorized official title is Owner/physician and has the following contact phone number (907) 373-9463.

The enumeration date for this NPI number is 10/25/2013 and was last updated on 10/20/2014.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 207Q00000X Family Medicine 5448 AK Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 K165366 MEDICARE PIN AK
2 1012605 MEDICAID AK

NPI Record

No. Field Name Field Value Field Definition 1
1 NPI 1003244211 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name WILD IRIS LLC The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider Other Organization Name WILD IRIS FAMILY MEDICINE AND MATERNITY CARE Other name by which the organization provider is or has been known.
6 Provider Other Organization Name Type Code 3 Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
7 Provider First Line Business Practice Location Address 851 E WESTPOINT DR The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
8 Provider Second Line Business Practice Location Address SUITE 207 The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
9 Provider Business Practice Location Address City Name WASILLA The city name in the location address of the provider being identified.
10 Provider Business Practice Location Address State Name AK The State code in the location of the provider being identified.
11 Provider Business Practice Location Address Postal Code 996547183 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
12 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
13 Provider Business Practice Location Address Telephone Number 9073739463 The telephone number associated with the location address of the provider being identified.
14 Provider Enumeration Date 10/25/2013 The date the provider was assigned a unique identifier (assigned an NPI).
15 Last Update Date 10/20/2014 The date that a record was last updated or changed.
16 Authorized Official Last Name HARRISON The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
17 Authorized Official First Name LISA The first name of the authorized official.
18 Authorized Official Title or Position OWNER/PHYSICIAN The title or position of the authorized official.
19 Authorized Official Telephone Number 9073739463 The 10-position telephone number of the authorized official.
20 Healthcare Provider Taxonomy Code 1 207Q00000X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
21 Provider License Number 1 5448 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
22 Provider License Number State Code 1 AK The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
23 Healthcare Provider Primary Taxonomy Switch 1 Y
24 Other Provider Identifier 1 K165366 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
25 Other Provider Identifier Type Code 1 08 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
26 Other Provider Identifier State 1 AK
27 Other Provider Identifier 2 1012605 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
28 Other Provider Identifier Type Code 2 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
29 Other Provider Identifier State 2 AK
30 Is Organization Subpart N
31 Authorized Official Name Prefix Text DR.
32 Authorized Official Credential Text M.D.
33 Healthcare Provider Taxonomy Group 1 193400000X SINGLE SPECIALTY GROUP

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This page was last updated on: 3/10/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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