Basic Information
| Provider Information | |||||||||
| NPI: | 1396140950 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALASKA PEDIATRIC SURGERY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 LAKE OTIS PKWY | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995085229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079297337 | ||||||||
| FaxNumber: | 9079297330 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 LAKE OTIS PKWY | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995085229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079297337 | ||||||||
| FaxNumber: | 9079297330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2014 | ||||||||
| LastUpdateDate: | 10/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROATEN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | BRENT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9077179871 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.