Provider Demographics
NPI:1932282381
Name:KIDNEY AND HYPERTENSION CLINIC OF ALASKA, INC
Entity Type:Organization
Organization Name:KIDNEY AND HYPERTENSION CLINIC OF ALASKA, INC
Other - Org Name:KIDNEY AND HYPERTENSION CLINIC OF ALASKA
Other - Org Type:Other Name
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GITOMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-375-5200
Mailing Address - Street 1:4015 LAKE OTIS PARKWAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-375-5200
Mailing Address - Fax:907-375-5203
Practice Address - Street 1:4015 LAKE OTIS PARKWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-375-5200
Practice Address - Fax:907-375-5203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5028207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020478Medicaid