Provider Demographics
NPI:1265834782
Name:SURGICAL SPECIALISTS OF ALASKA LLC
Entity Type:Organization
Organization Name:SURGICAL SPECIALISTS OF ALASKA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KERRE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-748-7398
Mailing Address - Street 1:5432 E NORTHERN LIGHTS BLVD # 510
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4713
Mailing Address - Country:US
Mailing Address - Phone:907-230-3734
Mailing Address - Fax:866-525-8738
Practice Address - Street 1:1690 W PIPESTONE DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-9741
Practice Address - Country:US
Practice Address - Phone:907-230-3734
Practice Address - Fax:866-525-8738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10024226207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1002426OtherBUSINESS LICENSE