Healthcare Provider Details

I. General information

NPI: 1659562189
Provider Name (Legal Business Name): CHINOOK SURGICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 LAKE OTIS PKWY STE 302
ANCHORAGE AK
99508-5230
US

IV. Provider business mailing address

PO BOX 143595
ANCHORAGE AK
99514-3595
US

V. Phone/Fax

Practice location:
  • Phone: 907-929-4263
  • Fax: 907-929-4267
Mailing address:
  • Phone: 907-929-4263
  • Fax: 907-929-4267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number278885
License Number StateAK

VIII. Authorized Official

Name: DR. MICHAEL A TODD
Title or Position: PRESIDENT
Credential: MD FACS
Phone: 907-929-4263