Healthcare Provider Details

I. General information

NPI: 1013083286
Provider Name (Legal Business Name): SHANE W CUMMINGS M D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 E DIMOND BLVD SUITE 1
ANCHORAGE AK
99515-2031
US

IV. Provider business mailing address

1310 E DIMOND BLVD SUITE 1
ANCHORAGE AK
99515-2031
US

V. Phone/Fax

Practice location:
  • Phone: 907-344-2400
  • Fax: 907-344-2404
Mailing address:
  • Phone: 907-344-2400
  • Fax: 907-344-2404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number5887
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5887
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: