Basic Information
| Provider Information | |||||||||
| NPI: | 1447451737 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALYESKA FAMILY MEDICINE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3841 PIPER STREET | ||||||||
| Address2: | SUITE T3162 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072581258 | ||||||||
| FaxNumber: | 9072581257 | ||||||||
| Practice Location | |||||||||
| Address1: | 3841 PIPER STREET | ||||||||
| Address2: | SUITE T3162 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072581258 | ||||||||
| FaxNumber: | 9072581257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 02/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | LANZA | ||||||||
| AuthorizedOfficialFirstName: | MARIO | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9072581258 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 3905 | AK | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | 4503 | AK | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | 3753 | AK | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 161169 | 01 | AK | PTAN | OTHER | 161406 | 01 | AK | MEDICARE PTAN | OTHER | MD3385 | 05 | AK | MEDICAID | MD37532 | 05 | AK | MEDICAID |