Provider Demographics
NPI:1548281215
Name:GUSTAVUS COMMUNITY CLINIC INC
Entity type:Organization
Organization Name:GUSTAVUS COMMUNITY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KARA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-697-3008
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:GUSTAVUS
Mailing Address - State:AK
Mailing Address - Zip Code:99826-0399
Mailing Address - Country:US
Mailing Address - Phone:907-697-3008
Mailing Address - Fax:907-697-3034
Practice Address - Street 1:42 DOLLY VARDEN LANE
Practice Address - Street 2:
Practice Address - City:GUSTAVUS
Practice Address - State:AK
Practice Address - Zip Code:99826
Practice Address - Country:US
Practice Address - Phone:907-697-3008
Practice Address - Fax:907-697-3034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
153051Medicare ID - Type Unspecified