Healthcare Provider Details

I. General information

NPI: 1174076822
Provider Name (Legal Business Name): ANCHORAGE BARIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2016
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 ARCTIC BLVD SUITE 101
ANCHORAGE AK
99503-5770
US

IV. Provider business mailing address

PO BOX 75039
CHICAGO IL
60675-5039
US

V. Phone/Fax

Practice location:
  • Phone: 907-644-8446
  • Fax: 907-644-8448
Mailing address:
  • Phone: 866-776-8150
  • Fax: 314-621-7276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number1033013
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN CLARK
Title or Position: PHYSICIAN
Credential: MD
Phone: 907-644-8446