Provider Demographics
NPI:1366615114
Name:SOUTHCENTRAL FOUNDATION
Entity type:Organization
Organization Name:SOUTHCENTRAL FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-729-4939
Mailing Address - Street 1:4501 DIPLOMACY DR
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5919
Mailing Address - Country:US
Mailing Address - Phone:907-729-4955
Mailing Address - Fax:
Practice Address - Street 1:10 DNR ROAD
Practice Address - Street 2:
Practice Address - City:MCGRATH
Practice Address - State:AK
Practice Address - Zip Code:99627
Practice Address - Country:US
Practice Address - Phone:907-524-3299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHCENTRAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-11
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK20467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty