Provider Demographics
NPI:1538192513
Name:ANCHORAGE PEDIATRIC GROUP
Entity type:Organization
Organization Name:ANCHORAGE PEDIATRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-562-2423
Mailing Address - Street 1:3340 PROVIDENCE DR
Mailing Address - Street 2:STE 500
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4616
Mailing Address - Country:US
Mailing Address - Phone:907-562-2423
Mailing Address - Fax:
Practice Address - Street 1:3340 PROVIDENCE DR
Practice Address - Street 2:STE 500
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4616
Practice Address - Country:US
Practice Address - Phone:907-562-2423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1744208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD3158Medicaid
AKMD2694Medicaid
AKMD1744Medicaid
AKMD1116Medicaid
AKMD3035Medicaid
AKD88988Medicare UPIN
AKMD3158Medicaid
AKMD3035Medicaid
AKMD1744Medicaid
AKG80005Medicare UPIN
AKE21883Medicare UPIN