Basic Information
| Provider Information | |||||||||
| NPI: | 1063466688 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALASKA IMAGING ASSOCIATES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHERN LIGHTS IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 140349 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995140349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077927920 | ||||||||
| FaxNumber: | 9077927901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2751 DEBARR RD STE 360 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995086809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077927920 | ||||||||
| FaxNumber: | 9077927921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PICKETT | ||||||||
| AuthorizedOfficialFirstName: | ROSEANN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9077927975 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | MDG950 | 05 | AK | MEDICAID | MDG515 | 05 | AK | MEDICAID | MDG525 | 05 | AK | MEDICAID |