=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194875831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLLEEN KERSGARD MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2007
-----------------------------------------------------
Last Update Date | 07/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2490 S WOODWORTH LOOP STE 499
-----------------------------------------------------
City | PALMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99645-7411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-746-7771
-----------------------------------------------------
Fax | 907-746-7798
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 75692
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60675-5692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-746-7771
-----------------------------------------------------
Fax | 907-746-7798
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 01055121A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 179758
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------