MEDICARE: PROVIDENCE ANCHORAGE ANESTHESIA MEDICAL GROUP, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659368397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE ANCHORAGE ANESTHESIA MEDICAL GROUP, P.C.

Provider Business Mailing Address
First Line	:	3300 PROVIDENCE DR
Second Line	:	SUITE 207
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-4616
Country	:	US
Telephone Number	:	907-561-0005
Fax Number	:	907-563-9140

Provider Business Practice Location Address
First Line	:	3300 PROVIDENCE DR
Second Line	:	SUITE 207
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-4616
Country	:	US
Telephone Number	:	907-561-0005
Fax Number	:	907-563-9140

Authorized Official
Title or Position	:	CHIEF HEALTH EXECUTIVE
Name	:	MR. JAMES BROOKS
Credential	:	CHE
Telephone Number	:	907-561-0005

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	08/22/2020

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