Provider Demographics
NPI:1639463953
Name:FULL SPECTRUM PEDIATRICS, PC
Entity Type:Organization
Organization Name:FULL SPECTRUM PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-677-1864
Mailing Address - Street 1:2841 DEBARR RD
Mailing Address - Street 2:BLDG A, SUITE 23
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2958
Mailing Address - Country:US
Mailing Address - Phone:907-677-1864
Mailing Address - Fax:907-868-5167
Practice Address - Street 1:2841 DEBARR RD
Practice Address - Street 2:BLDG A, SUITE 23
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2958
Practice Address - Country:US
Practice Address - Phone:907-677-1864
Practice Address - Fax:907-868-5167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4587261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK3255Medicaid