Provider Demographics
NPI:1770605214
Name:ANCHORAGE ENDOSCOPY CENTER, LLC
Entity type:Organization
Organization Name:ANCHORAGE ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:907-222-9129
Mailing Address - Street 1:2841 DEBARR RD STE 51
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2958
Mailing Address - Country:US
Mailing Address - Phone:907-222-9129
Mailing Address - Fax:907-279-7346
Practice Address - Street 1:2841 DEBARR RD STE 51
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2932
Practice Address - Country:US
Practice Address - Phone:907-222-3636
Practice Address - Fax:907-222-5031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK02-C0001005261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKAS6329Medicaid
AKK150567Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
AKAS6329Medicaid