Healthcare Provider Details

I. General information

NPI: 1376529610
Provider Name (Legal Business Name): THE CHILDRENS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 DALE ST STE 213
ANCHORAGE AK
99508-5496
US

IV. Provider business mailing address

4001 DALE ST STE 213
ANCHORAGE AK
99508-5496
US

V. Phone/Fax

Practice location:
  • Phone: 907-562-2944
  • Fax: 907-562-6321
Mailing address:
  • Phone: 907-562-2944
  • Fax: 907-562-6321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number26446
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierGR0120
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: DANIEL EDWARD TULIP
Title or Position: PRESIDENT
Credential: MD
Phone: 907-562-2944