Kodiak Island Ambulatory Care Clinic Inc.

Primary specialty

Urgent Care Clinic/CenterTaxonomy code 261QU0200X

License

DL282350 Issued in AK

Legal business name

KODIAK ISLAND AMBULATORY CARE CLINIC INC.

Practice address

202 Center Ave
Ste. 102
Kodiak, AK 99615-1126

Phone

(907) 486-6188

Fax

(907) 486-6146

NPI assigned

Jan 23, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

John M. Koller, M.D.NPI 1588721195

Title

President

Phone

(907) 486-6188

Specialties & licenses 1

Addresses

Other identifiers 5

Medicare fee-for-service enrollment

Enrolled in AK

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Interoperability endpoints

• FHIR API: https://api.platform.athenahealth.com/8408/brand/1/csg/1/fhir/r4

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• John M Koller, M.D.

  • Family Medicine Physician
  • Kodiak, AK
  • NPI 1588721195
  Medicare reassignment NPD Authorized official
• Stacey Lynn Hyles, A.R.N.P

  • Family Nurse Practitioner
  • Moyock, NC
  • NPI 1366799512
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169510400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1305504000000",
    "number": "1366596504",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1126",
            "city": "KODIAK",
            "state": "AK",
            "postal_code": "996151126",
            "telephone_number": "907-486-6188",
            "fax_number": "907-486-6146"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "202 CENTER AVE",
            "address_2": "STE. 102",
            "city": "KODIAK",
            "state": "AK",
            "postal_code": "996151126",
            "telephone_number": "907-486-6188",
            "fax_number": "907-486-6146"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KODIAK ISLAND AMBULATORY CARE CLINIC INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-23",
        "last_updated": "2011-05-16",
        "status": "A",
        "authorized_official_last_name": "KOLLER",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "M.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "907-486-6188",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QU0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Urgent Care",
            "state": "AK",
            "license": "DL282350",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA NUMBER",
            "identifier": "02D0985615",
            "state": "AK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BUSINESS LICENSE NUMBER",
            "identifier": "DL282350",
            "state": "AK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE DME",
            "identifier": "6270850001",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "K162500",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "MD10072",
            "state": "AK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Kodiak Island Assisted Living, LLC
• Kodiak Island Assisted Living, LLC
• Kodiak Island Family Dentistry
• Kodiak Island Health Care Foundation (Kodiak Community Health Center)
• Kodiak Island Health Care Foundation (Kodiak Community Health Center Pharmacy)

• Urgent Care Clinic/Center in Kodiak, AK
• Providers in Kodiak, AK by specialty
• Urgent Care Clinic/Center in Alaska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 16, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.