Provider Demographics
NPI:1891790184
Name:INDEPENDENCE HEALTHCARE PC
Entity type:Organization
Organization Name:INDEPENDENCE HEALTHCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:KRULL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-262-6454
Mailing Address - Street 1:291 N FIREWEED ST
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7540
Mailing Address - Country:US
Mailing Address - Phone:907-262-6454
Mailing Address - Fax:907-262-0832
Practice Address - Street 1:289 N FIREWEED ST STE D
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7570
Practice Address - Country:US
Practice Address - Phone:907-262-6454
Practice Address - Fax:907-262-0832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK264120261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK4127920001OtherDMERC SUPPLIER NO.
AK264120OtherAK. BUSINESS LICENSE
AKMDG 575Medicaid
AKMDG 575Medicaid