Provider Demographics
NPI:1063694750
Name:MARVIN JOHN GRENDAHL MD A PROFESSIONAL CORP.
Entity type:Organization
Organization Name:MARVIN JOHN GRENDAHL MD A PROFESSIONAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMIN.
Authorized Official - Prefix:MS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEINGANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-561-1917
Mailing Address - Street 1:3500 LATOUCHE ST STE 280
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4261
Mailing Address - Country:US
Mailing Address - Phone:907-561-1917
Mailing Address - Fax:907-563-5373
Practice Address - Street 1:3500 LATOUCHE ST STE 280
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4261
Practice Address - Country:US
Practice Address - Phone:907-561-1917
Practice Address - Fax:907-563-5373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMD3686207W00000X
AKMD1417207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1417Medicaid
AKKOOWFBMCAMedicare PIN
AKMD1417Medicaid