Provider Demographics
NPI:1215904156
Name:KUSSRO, ERIK MARSHALL (DO)
Entity type:Individual
Prefix:
First Name:ERIK
Middle Name:MARSHALL
Last Name:KUSSRO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3831 PIPER ST
Mailing Address - Street 2:SUITE S450
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4672
Mailing Address - Country:US
Mailing Address - Phone:907-258-6999
Mailing Address - Fax:907-258-9470
Practice Address - Street 1:3831 PIPER ST
Practice Address - Street 2:SUITE S450
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4672
Practice Address - Country:US
Practice Address - Phone:907-258-6999
Practice Address - Fax:907-258-9470
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2454208100000X
AK50682081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD4485Medicaid
AKMD4485Medicaid
H78452Medicare UPIN
AK0000WCYBPMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER