Healthcare Provider Details

I. General information

NPI: 1609051986
Provider Name (Legal Business Name): KODIAK ISLAND MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2008
Last Update Date: 01/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 E REZANOF DR
KODIAK AK
99615
US

IV. Provider business mailing address

1818 E REZANOF DR
KODIAK AK
99615
US

V. Phone/Fax

Practice location:
  • Phone: 907-486-6065
  • Fax: 907-486-2248
Mailing address:
  • Phone: 907-486-6065
  • Fax: 907-486-2248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARK E WITHROW
Title or Position: OWNER MD
Credential: MD
Phone: 907-486-6065