Healthcare Provider Details

I. General information

NPI: 1578578928
Provider Name (Legal Business Name): ALASKA CARDIOVASCULAR ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3340 PROVIDENCE DR #466
ANCHORAGE AK
99508-4616
US

IV. Provider business mailing address

3340 PROVIDENCE DR #466
ANCHORAGE AK
99508-4616
US

V. Phone/Fax

Practice location:
  • Phone: 907-263-2200
  • Fax: 907-276-0366
Mailing address:
  • Phone: 907-263-2200
  • Fax: 907-276-0366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number3693
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number3693
License Number StateAK

VIII. Authorized Official

Name: COLLEEN M COUGHLIN
Title or Position: MANAGER
Credential: M.D.
Phone: 907-263-2200