Provider Demographics
NPI:1508089046
Name:MEDICAL NETWORK OF ALASKA, LLC
Entity Type:Organization
Organization Name:MEDICAL NETWORK OF ALASKA, LLC
Other - Org Name:CAPSTONE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RCM
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:BLOMKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-864-4625
Mailing Address - Street 1:3122 E MERIDIAN PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7255
Mailing Address - Country:US
Mailing Address - Phone:907-357-9590
Mailing Address - Fax:907-357-9593
Practice Address - Street 1:3122 E MERIDIAN PARK LOOP
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7255
Practice Address - Country:US
Practice Address - Phone:907-357-9590
Practice Address - Fax:907-357-9593
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAPSTONE FAMILY MEDICINE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-11
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4593174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1651007Medicaid
AKMG0651Medicaid
AKK167625Medicare PIN