Healthcare Provider Details

I. General information

NPI: 1396278891
Provider Name (Legal Business Name): MARK AHLENIUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 A JACKSON AVE MADIGAN ARMY MEDICAL CENTER
JOINT BASE LEWIS MCCHORD WA
98431-4504
US

IV. Provider business mailing address

9040-A JACKSON AVE MADIGAN HOSPITAL
FORT LEWIS WA
98431
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number838
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101266050
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: