Provider Demographics
NPI:1538772173
Name:EAGLE HEALTH ALASKA
Entity type:Organization
Organization Name:EAGLE HEALTH ALASKA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NINEFELDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-201-1102
Mailing Address - Street 1:PO BOX 671336
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567-1336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2015 MERRILL FIELD DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-4137
Practice Address - Country:US
Practice Address - Phone:907-201-1102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1652136Medicaid