Basic Information
| Provider Information | |||||||||
| NPI: | 1174882971 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL GROUP OF ALASKA | ||||||||
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| OtherOrganizationName: | ALGONE INTERNATIONAL PAIN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3190 E MERIDIAN PARK LOOP STE 207 | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996547422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073577710 | ||||||||
| FaxNumber: | 9073577720 | ||||||||
| Practice Location | |||||||||
| Address1: | 3190 E MERDIAN PARK LOOP | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073739460 | ||||||||
| FaxNumber: | 9073739461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2012 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | HENRY-MUSA | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9073577710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LYNX MEDICAL SERVICES ORGANIZATION | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | 949810 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 332B00000X | 1070929 | AK | N | Suppliers | Durable Medical Equipment & Medical Supplies | 208VP0000X | 1070929 | AK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1658871 | 05 | AK | MEDICAID |