Provider Demographics
NPI:1962539775
Name:PEDIATRIC GASTROENTEROLOGY OF ALASKA, LLC
Entity type:Organization
Organization Name:PEDIATRIC GASTROENTEROLOGY OF ALASKA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-276-5517
Mailing Address - Street 1:3340 PROVIDENCE DR
Mailing Address - Street 2:SUITE 567
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4616
Mailing Address - Country:US
Mailing Address - Phone:907-276-5517
Mailing Address - Fax:907-279-3655
Practice Address - Street 1:3340 PROVIDENCE DR
Practice Address - Street 2:SUITE 567
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4616
Practice Address - Country:US
Practice Address - Phone:907-276-5517
Practice Address - Fax:907-279-3655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
153393Medicare ID - Type Unspecified