Provider Demographics
NPI:1174076822
Name:ANCHORAGE BARIATRICS, LLC
Entity type:Organization
Organization Name:ANCHORAGE BARIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-644-8446
Mailing Address - Street 1:PO BOX 75039
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-5039
Mailing Address - Country:US
Mailing Address - Phone:866-776-8150
Mailing Address - Fax:314-621-7276
Practice Address - Street 1:3909 ARCTIC BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-5770
Practice Address - Country:US
Practice Address - Phone:907-644-8446
Practice Address - Fax:907-644-8448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-29
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0850X, 261QM0855X
AK1033013208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health