Basic Information
Provider Information
NPI: 1073130415
EntityType: 2
ReplacementNPI:  
OrganizationName: ARCTIC AURORA, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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Mailing Information
Address1: PO BOX 241769
Address2:  
City: ANCHORAGE
State: AK
PostalCode: 995241769
CountryCode: US
TelephoneNumber: 9077702380
FaxNumber: 9077702341
Practice Location
Address1: 701 E TUDOR RD STE 140
Address2:  
City: ANCHORAGE
State: AK
PostalCode: 995037459
CountryCode: US
TelephoneNumber: 9076461009
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/01/2020
LastUpdateDate: 07/01/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: BAKER
AuthorizedOfficialFirstName: BETH
AuthorizedOfficialMiddleName: A
AuthorizedOfficialTitleorPosition: OWNER / PHYSICIAN
AuthorizedOfficialTelephone: 9073514232
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate: 07/01/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RP1001X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease

ID Information
IDTypeStateIssuerDescription
MD1863105AK MEDICAID


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