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
1 NPI 1003244211
2 Entity Type Code 2
3 Employer Identification Number EIN
4 Provider Organization Name Legal Business Name WILD IRIS LLC
5 Provider Other Organization Name WILD IRIS FAMILY MEDICINE AND MATERNITY CARE
6 Provider Other Organization Name Type Code 3
7 Provider First Line Business Practice Location Address 851 E WESTPOINT DR
8 Provider Second Line Business Practice Location Address SUITE 207
9 Provider Business Practice Location Address City Name WASILLA
10 Provider Business Practice Location Address State Name AK
11 Provider Business Practice Location Address Postal Code 996547183
12 Provider Business Practice Location Address Country Code If outside U S US
13 Provider Business Practice Location Address Telephone Number 9073739463
14 Provider Enumeration Date 10/25/2013
15 Last Update Date 10/20/2014
16 Authorized Official Last Name HARRISON
17 Authorized Official First Name LISA
18 Authorized Official Title or Position OWNER/PHYSICIAN
19 Authorized Official Telephone Number 9073739463
20 Healthcare Provider Taxonomy Code 1 207Q00000X
21 Provider License Number 1 5448
22 Provider License Number State Code 1 AK
23 Healthcare Provider Primary Taxonomy Switch 1 Y
24 Other Provider Identifier 1 K165366
25 Other Provider Identifier Type Code 1 08
26 Other Provider Identifier State 1 AK
27 Other Provider Identifier 2 1012605
28 Other Provider Identifier Type Code 2 05
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: 11/14/2014
All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.