Provider Demographics
NPI:1386391696
Name:REDOUBT MEDICAL GROUP LLC.
Entity type:Organization
Organization Name:REDOUBT MEDICAL GROUP LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:ITANO
Authorized Official - Last Name:MERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:907-283-6030
Mailing Address - Street 1:416 FRONTAGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7770
Mailing Address - Country:US
Mailing Address - Phone:907-283-6030
Mailing Address - Fax:907-283-3194
Practice Address - Street 1:416 FRONTAGE RD STE 200
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7770
Practice Address - Country:US
Practice Address - Phone:907-283-6030
Practice Address - Fax:907-283-3194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-07
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center