Provider Demographics
NPI:1447451737
Name:ALYESKA FAMILY MEDICINE INC
Entity type:Organization
Organization Name:ALYESKA FAMILY MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:LANZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-258-1258
Mailing Address - Street 1:3841 PIPER STREET
Mailing Address - Street 2:SUITE T3162
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-258-1258
Mailing Address - Fax:907-258-1257
Practice Address - Street 1:3841 PIPER STREET
Practice Address - Street 2:SUITE T3162
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-258-1258
Practice Address - Fax:907-258-1257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3753208D00000X
AK3905208D00000X
AK4503208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK161169OtherPTAN
AK161406OtherMEDICARE PTAN
AKMD3385Medicaid
AKMD37532Medicaid
AKMD3385Medicaid
AK161169OtherPTAN
AKK160658Medicare PIN