Provider Demographics
NPI:1659368397
Name:PROVIDENCE ANCHORAGE ANESTHESIA MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:PROVIDENCE ANCHORAGE ANESTHESIA MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF HEALTH EXECUTIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:CHE
Authorized Official - Phone:907-561-0005
Mailing Address - Street 1:3300 PROVIDENCE DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4616
Mailing Address - Country:US
Mailing Address - Phone:907-561-0005
Mailing Address - Fax:907-563-9140
Practice Address - Street 1:3300 PROVIDENCE DR
Practice Address - Street 2:SUITE 207
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4616
Practice Address - Country:US
Practice Address - Phone:907-561-0005
Practice Address - Fax:907-563-9140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDG394Medicaid
AKMDG395Medicaid
AKMDG394Medicaid