Healthcare Provider Details

I. General information

NPI: 1962539775
Provider Name (Legal Business Name): PEDIATRIC GASTROENTEROLOGY OF ALASKA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3340 PROVIDENCE DR SUITE 567
ANCHORAGE AK
99508-4616
US

IV. Provider business mailing address

3340 PROVIDENCE DR SUITE 567
ANCHORAGE AK
99508-4616
US

V. Phone/Fax

Practice location:
  • Phone: 907-276-5517
  • Fax: 907-279-3655
Mailing address:
  • Phone: 907-276-5517
  • Fax: 907-279-3655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES ALLAN PRATT
Title or Position: MANAGER
Credential: M.D.
Phone: 907-276-5517