Healthcare Provider Details

I. General information

NPI: 1568704229
Provider Name (Legal Business Name): THAT'S MY PEDS GI PEDIATRIC GASTROENTEROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 LAUREL ST SUITE 201
ANCHORAGE AK
99508-5392
US

IV. Provider business mailing address

PO BOX 241769
ANCHORAGE AK
99524-1769
US

V. Phone/Fax

Practice location:
  • Phone: 907-743-6944
  • Fax: 907-743-0694
Mailing address:
  • Phone: 907-770-2380
  • Fax: 907-770-2341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number984995
License Number StateAK

VIII. Authorized Official

Name: JOSEPH E BEATY
Title or Position: BILLING AGENT
Credential:
Phone: 907-770-2380