Healthcare Provider Details

I. General information

NPI: 1619935558
Provider Name (Legal Business Name): ALASKA KIDNEY & DIABETES ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 01/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3260 PROVIDENCE DR #523
ANCHORAGE AK
99508-4608
US

IV. Provider business mailing address

3260 PROVIDENCE DR #523
ANCHORAGE AK
99508-4608
US

V. Phone/Fax

Practice location:
  • Phone: 907-569-1049
  • Fax: 907-563-4564
Mailing address:
  • Phone: 907-569-1049
  • Fax: 907-563-4564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LESLIE A. GLASGOW
Title or Position: CEO
Credential: MD
Phone: 907-569-1049