Healthcare Provider Details

I. General information

NPI: 1659982924
Provider Name (Legal Business Name): KLONDIKE MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2020
Last Update Date: 02/27/2021
Certification Date: 02/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2421 E TUDOR RD STE 105
ANCHORAGE AK
99507-1166
US

IV. Provider business mailing address

11520 SAINT CHARLES ROCK RD STE 105
BRIDGETON MO
63044-2732
US

V. Phone/Fax

Practice location:
  • Phone: 314-402-7432
  • Fax:
Mailing address:
  • Phone: 314-312-5588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: NAGARAJ V KUNDA
Title or Position: OWNER/CEO
Credential:
Phone: 314-312-5588