1295032910 NPI number — KODIAK BOARD CERTIFIED RADIOLOGY, LLC

Table of content: (NPI 1295032910)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295032910 NPI number — KODIAK BOARD CERTIFIED RADIOLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KODIAK BOARD CERTIFIED RADIOLOGY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295032910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3427 E TUDOR RD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99507-1282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-563-3679
Provider Business Mailing Address Fax Number:
907-563-9070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1915 E REZANOF DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KODIAK
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99615-6602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-486-9581
Provider Business Practice Location Address Fax Number:
907-486-9523
Provider Enumeration Date:
02/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BIAS
Authorized Official First Name:
KAY
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
907-565-8005

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  6152 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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