Provider Demographics
NPI:1164166088
Name:SRA D.O. LLC
Entity Type:Organization
Organization Name:SRA D.O. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:AUGUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:907-529-0103
Mailing Address - Street 1:PO BOX 241889
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99524-1889
Mailing Address - Country:US
Mailing Address - Phone:907-563-1777
Mailing Address - Fax:907-561-7464
Practice Address - Street 1:2530 DEBARR RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2948
Practice Address - Country:US
Practice Address - Phone:907-258-7575
Practice Address - Fax:907-561-7464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1730694Medicaid