Healthcare Provider Details

I. General information

NPI: 1538192513
Provider Name (Legal Business Name): ANCHORAGE PEDIATRIC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3340 PROVIDENCE DR STE 500
ANCHORAGE AK
99508-4616
US

IV. Provider business mailing address

3340 PROVIDENCE DR STE 500
ANCHORAGE AK
99508-4616
US

V. Phone/Fax

Practice location:
  • Phone: 907-562-2423
  • Fax:
Mailing address:
  • Phone: 907-562-2423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1744
License Number StateAK

VII. Legacy identifiers

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

# 1
IdentifierMD3158
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 2
IdentifierMD2694
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 3
IdentifierMD1744
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 4
IdentifierMD1116
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 5
IdentifierMD3035
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: DR. CHARLES RYAN
Title or Position: SENIOR PARTNER
Credential: MD
Phone: 907-562-2423