Provider Demographics
NPI:1659010361
Name:A4 SPECIALTY MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:A4 SPECIALTY MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-223-7347
Mailing Address - Street 1:510 W TUDOR RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-6649
Mailing Address - Country:US
Mailing Address - Phone:907-223-7347
Mailing Address - Fax:
Practice Address - Street 1:510 W TUDOR RD STE 1
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-6649
Practice Address - Country:US
Practice Address - Phone:907-223-7347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty