Basic Information
| Provider Information | |||||||||
| NPI: | 1659368397 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE ANCHORAGE ANESTHESIA MEDICAL GROUP, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 PROVIDENCE DR | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075610005 | ||||||||
| FaxNumber: | 9075639140 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 PROVIDENCE DR | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075610005 | ||||||||
| FaxNumber: | 9075639140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BROOKS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF HEALTH EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 9075610005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CHE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | MDG394 | 05 | AK | MEDICAID | MDG395 | 05 | AK | MEDICAID |