Provider Demographics
NPI:1184232670
Name:ADVANCED MEDICAL GROUP
Entity type:Organization
Organization Name:ADVANCED MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:IGOREVNA
Authorized Official - Last Name:LUPAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-691-4977
Mailing Address - Street 1:PO BOX 230508
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99523-0508
Mailing Address - Country:US
Mailing Address - Phone:907-691-4977
Mailing Address - Fax:907-313-7450
Practice Address - Street 1:135 W DIMOND BLVD STE 104C
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-1907
Practice Address - Country:US
Practice Address - Phone:907-691-4977
Practice Address - Fax:907-313-7450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-21
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care