Healthcare Provider Details

I. General information

NPI: 1326753021
Provider Name (Legal Business Name): MEDICAL NETWORK OF ALASKA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2023
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 LAKE OTIS PKWY STE 220
ANCHORAGE AK
99508-5230
US

IV. Provider business mailing address

3122 E MERIDIAN PARK LOOP
WASILLA AK
99654-7255
US

V. Phone/Fax

Practice location:
  • Phone: 907-563-3145
  • Fax: 907-561-3967
Mailing address:
  • Phone: 907-864-4625
  • Fax: 907-357-9593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JACQUELYN RENEE BLOMKER
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 907-864-4625