Basic Information
| Provider Information | |||||||||
| NPI: | 1609176783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALGONE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 870904 | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996870904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073739460 | ||||||||
| FaxNumber: | 9073739461 | ||||||||
| Practice Location | |||||||||
| Address1: | 3066 E MERIDIAN PARK LOOP | ||||||||
| Address2: | #1 | ||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996547299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073739460 | ||||||||
| FaxNumber: | 9073739461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2010 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | GRISSOM | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9073739460 | ||||||||
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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 | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.