Healthcare Provider Details

I. General information

NPI: 1033128335
Provider Name (Legal Business Name): ALASKA COLORECTAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 DEBARR RD STE 280
ANCHORAGE AK
99508-2953
US

IV. Provider business mailing address

2751 DEBARR RD STE 280
ANCHORAGE AK
99508-2953
US

V. Phone/Fax

Practice location:
  • Phone: 907-222-1401
  • Fax: 907-222-1402
Mailing address:
  • Phone: 907-222-1401
  • Fax: 907-222-1402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number4148
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number450
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number838
License Number StateAK

VIII. Authorized Official

Name: JUNE M. GEORGE
Title or Position: OWNER
Credential: M.D.
Phone: 907-222-1401