Provider Demographics
NPI:1760458491
Name:SOUTHEAST ALASKA REGIONAL CENTER
Entity Type:Organization
Organization Name:SOUTHEAST ALASKA REGIONAL CENTER
Other - Org Name:SEARCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-622-3569
Mailing Address - Street 1:PO BOX 241889
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99524-1889
Mailing Address - Country:US
Mailing Address - Phone:907-563-1777
Mailing Address - Fax:907-561-7464
Practice Address - Street 1:2490 S WOODWORTH
Practice Address - Street 2:SUITE 410
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645
Practice Address - Country:US
Practice Address - Phone:907-745-9230
Practice Address - Fax:907-745-9233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK288794291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD47212Medicaid
AKH71992Medicare UPIN
AK153174Medicare ID - Type UnspecifiedNORIDIAN MEDICARE