Provider Demographics
NPI:1124078019
Name:BETHEL FAMILY CLINIC
Entity type:Organization
Organization Name:BETHEL FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-543-9852
Mailing Address - Street 1:PO BOX 1908
Mailing Address - Street 2:631 MAIN STREET
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-1908
Mailing Address - Country:US
Mailing Address - Phone:907-543-3773
Mailing Address - Fax:907-543-3545
Practice Address - Street 1:631 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-1908
Practice Address - Country:US
Practice Address - Phone:907-543-3773
Practice Address - Fax:907-543-3545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1029936Medicaid
AK02-1835OtherMEDICARE PART A PTAN
AK02-1835OtherMEDICARE PART A PTAN