Healthcare Provider Details

I. General information

NPI: 1033910195
Provider Name (Legal Business Name): MGM ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 03/24/2025
Certification Date: 03/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 F ST
ANCHORAGE AK
99501-4347
US

IV. Provider business mailing address

1220 F ST
ANCHORAGE AK
99501-4347
US

V. Phone/Fax

Practice location:
  • Phone: 907-802-3696
  • Fax: 907-531-1303
Mailing address:
  • Phone: 907-802-3696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: WILLY GAMA
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 907-802-3696