Provider Demographics
NPI:1619935558
Name:ALASKA KIDNEY & DIABETES ASSOCIATION
Entity Type:Organization
Organization Name:ALASKA KIDNEY & DIABETES ASSOCIATION
Other - Org Name:BONGO MEDICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GLASGOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-569-1049
Mailing Address - Street 1:3260 PROVIDENCE DR
Mailing Address - Street 2:#523
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4608
Mailing Address - Country:US
Mailing Address - Phone:907-569-1049
Mailing Address - Fax:907-563-4564
Practice Address - Street 1:3260 PROVIDENCE DR
Practice Address - Street 2:#523
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4608
Practice Address - Country:US
Practice Address - Phone:907-569-1049
Practice Address - Fax:907-563-4564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK152825Medicare PIN