Basic Information
| Provider Information | |||||||||
| NPI: | 1720155856 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANCHORAGE OSTEOPATHIC MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E DIMOND BLVD | ||||||||
| Address2: | #12 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995151908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073417727 | ||||||||
| FaxNumber: | 9073417760 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 E DIMOND BLVD | ||||||||
| Address2: | #12 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995151908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073417727 | ||||||||
| FaxNumber: | 9073417760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | OSWALD | ||||||||
| AuthorizedOfficialFirstName: | MAURY | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9073417727 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2781 | AK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD2781 | 05 | AK | MEDICAID |