Provider Demographics
NPI:1306022314
Name:KONRAD C KALTENBORN MD
Entity Type:Organization
Organization Name:KONRAD C KALTENBORN MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SYSTEMS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-751-8116
Mailing Address - Street 1:PO BOX 241889
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99524-1889
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 LAKE OTIS PKWY
Practice Address - Street 2:STE 305
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5229
Practice Address - Country:US
Practice Address - Phone:907-751-8116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-21
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK150054Medicare PIN