=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689716185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALASKA UROLOGICAL INSTITUTE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 06/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 188 W NORTHERN LIGHTS BLVD SUITE 800
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-276-2806
-----------------------------------------------------
Fax | 907-276-2815
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 188 W NORTHERN LIGHTS BLVD SUITE 800
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-276-2806
-----------------------------------------------------
Fax | 907-276-2815
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WILLIAM R CLARK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 907-276-2844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------