Provider Demographics
NPI:1720155856
Name:ANCHORAGE OSTEOPATHIC MEDICAL CLINIC
Entity Type:Organization
Organization Name:ANCHORAGE OSTEOPATHIC MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAURY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:OSWALD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:907-341-7727
Mailing Address - Street 1:300 E DIMOND BLVD
Mailing Address - Street 2:#12
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-1908
Mailing Address - Country:US
Mailing Address - Phone:907-341-7727
Mailing Address - Fax:907-341-7760
Practice Address - Street 1:300 E DIMOND BLVD
Practice Address - Street 2:#12
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-1908
Practice Address - Country:US
Practice Address - Phone:907-341-7727
Practice Address - Fax:907-341-7760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2781Medicaid