Provider Demographics
NPI:1780867978
Name:REGINA S CHENNAULT MD PC
Entity Type:Organization
Organization Name:REGINA S CHENNAULT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHENNAULT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-264-1204
Mailing Address - Street 1:2841 DEBARR ROAD
Mailing Address - Street 2:SUITE 42
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2956
Mailing Address - Country:US
Mailing Address - Phone:907-264-1204
Mailing Address - Fax:907-264-1995
Practice Address - Street 1:2841 DEBARR ROAD
Practice Address - Street 2:SUITE 42
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2956
Practice Address - Country:US
Practice Address - Phone:907-264-1204
Practice Address - Fax:907-264-1995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5170208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD8085Medicaid
AKMD8085Medicaid
F91164Medicare UPIN