Provider Demographics
NPI:1295032910
Name:KODIAK BOARD CERTIFIED RADIOLOGY, LLC
Entity Type:Organization
Organization Name:KODIAK BOARD CERTIFIED RADIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-565-8005
Mailing Address - Street 1:3427 E TUDOR RD STE A
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1282
Mailing Address - Country:US
Mailing Address - Phone:907-563-3679
Mailing Address - Fax:907-563-9070
Practice Address - Street 1:1915 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6602
Practice Address - Country:US
Practice Address - Phone:907-486-9581
Practice Address - Fax:907-486-9523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK61522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty