Provider Demographics
NPI:1730820358
Name:INNOVATIVE NEUROSURGERY ASSOCIATES, LLC
Entity type:Organization
Organization Name:INNOVATIVE NEUROSURGERY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:PAULSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-243-0339
Mailing Address - Street 1:2751 DEBARR RD STE B285
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-6817
Mailing Address - Country:US
Mailing Address - Phone:907-243-0339
Mailing Address - Fax:
Practice Address - Street 1:2751 DEBARR RD STE B285
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-6817
Practice Address - Country:US
Practice Address - Phone:907-243-0339
Practice Address - Fax:907-243-0337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1670001Medicaid