Provider Demographics
NPI:1720080328
Name:ALASKA BONE & JOINT INSTITUTE PC
Entity Type:Organization
Organization Name:ALASKA BONE & JOINT INSTITUTE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-334-6788
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 1:2751 DEBARR RD
Practice Address - Street 2:SUITE B285
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2953
Practice Address - Country:US
Practice Address - Phone:907-334-6788
Practice Address - Fax:907-334-6466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK309662207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK607725300OtherFEDERAL WORK COMP/OWCP
AK160177Medicare ID - Type UnspecifiedNORIDIAN MEDICARE
AKH45167Medicare UPIN