Provider Demographics
NPI:1316942048
Name:ALASKA SPINE INSTITUTE SURGERY CENTER, LLC
Entity type:Organization
Organization Name:ALASKA SPINE INSTITUTE SURGERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANNA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:RN CASC
Authorized Official - Phone:907-341-5269
Mailing Address - Street 1:3801 LAKE OTIS PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5234
Mailing Address - Country:US
Mailing Address - Phone:907-563-1555
Mailing Address - Fax:907-563-1222
Practice Address - Street 1:3801 LAKE OTIS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5234
Practice Address - Country:US
Practice Address - Phone:907-563-1555
Practice Address - Fax:907-563-1222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK719851261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKAS2249Medicaid
AKAS2249Medicaid