Basic Information
| Provider Information | |||||||||
| NPI: | 1528134046 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLUB | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 WOLFF DRIVE | ||||||||
| Address2: | |||||||||
| City: | SITKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077472932 | ||||||||
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| Practice Location | |||||||||
| Address1: | 209 MOLLER AVE | ||||||||
| Address2: | |||||||||
| City: | SITKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998357142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077471701 | ||||||||
| FaxNumber: | 9077471726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 12/12/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4751 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD8651 | 05 | AK | MEDICAID |