Healthcare Provider Details

I. General information

NPI: 1164166088
Provider Name (Legal Business Name): SRA D.O. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 DEBARR RD
ANCHORAGE AK
99508-2948
US

IV. Provider business mailing address

PO BOX 241889
ANCHORAGE AK
99524-1889
US

V. Phone/Fax

Practice location:
  • Phone: 907-258-7575
  • Fax: 907-561-7464
Mailing address:
  • Phone: 907-563-1777
  • Fax: 907-561-7464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1730694
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: DR. SPENCER RICHARD AUGUSTIN
Title or Position: PRESIDENT
Credential: DO
Phone: 907-529-0103