Provider Demographics
NPI:1063150043
Name:KATMAI ONCOLOGY GROUP, LLC
Entity type:Organization
Organization Name:KATMAI ONCOLOGY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:907-677-5826
Mailing Address - Street 1:PO BOX 74900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-4900
Mailing Address - Country:US
Mailing Address - Phone:602-441-9520
Mailing Address - Fax:602-441-9524
Practice Address - Street 1:12001 BUSINESS BLVD STE 3C
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7743
Practice Address - Country:US
Practice Address - Phone:907-562-0321
Practice Address - Fax:907-562-2683
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KATMAI ONCOLOGY GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty