Provider Demographics
NPI:1285752857
Name:ALASKA NEURODIAGNOSTIC AND REHABILITATION MEDICINE, INC
Entity type:Organization
Organization Name:ALASKA NEURODIAGNOSTIC AND REHABILITATION MEDICINE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/ ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-562-2600
Mailing Address - Street 1:4120 LAUREL ST STE 206
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5392
Mailing Address - Country:US
Mailing Address - Phone:907-562-2600
Mailing Address - Fax:907-562-2602
Practice Address - Street 1:4120 LAUREL ST STE 206
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5392
Practice Address - Country:US
Practice Address - Phone:907-562-2600
Practice Address - Fax:907-562-2602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA2061208100000X
AK2061208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2061Medicaid
AKMDG145Medicaid
AKMD2061Medicaid
AKMDG145Medicaid