Healthcare Provider Details

I. General information

NPI: 1285752857
Provider Name (Legal Business Name): ALASKA NEURODIAGNOSTIC AND REHABILITATION MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 LAUREL ST STE 206
ANCHORAGE AK
99508-5392
US

IV. Provider business mailing address

4120 LAUREL ST STE 206
ANCHORAGE AK
99508-5392
US

V. Phone/Fax

Practice location:
  • Phone: 907-562-2600
  • Fax: 907-562-2602
Mailing address:
  • Phone: 907-562-2600
  • Fax: 907-562-2602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberAA2061
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2061
License Number StateAK

VII. Legacy identifiers

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

# 1
IdentifierMD2061
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 2
IdentifierMDG145
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: MATTHEW EDWARD MOORE
Title or Position: CFO/ ADMINISTRATOR
Credential:
Phone: 907-562-2600