Provider Demographics
NPI:1033135447
Name:DENALI CARDIAC AND THORACIC SURGICAL GROUP LLC
Entity Type:Organization
Organization Name:DENALI CARDIAC AND THORACIC SURGICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENTON
Authorized Official - Middle Name:EDGAR
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:907-375-2000
Mailing Address - Street 1:PO BOX 3482
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83877-3482
Mailing Address - Country:US
Mailing Address - Phone:208-209-6170
Mailing Address - Fax:208-209-6169
Practice Address - Street 1:2751 DEBARR RD STE B320
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-6805
Practice Address - Country:US
Practice Address - Phone:907-375-2000
Practice Address - Fax:907-375-5558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK152964OtherMEDICARE ID