1386759470 NPI number — FAIRBANKS CANCER CARE PHYSICIANS

Table of content: (NPI 1386759470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386759470 NPI number — FAIRBANKS CANCER CARE PHYSICIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRBANKS CANCER CARE PHYSICIANS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386759470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1640 COWLES ST
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
FAIRBANKS
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99701-5925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-452-4768
Provider Business Mailing Address Fax Number:
907-452-1009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1640 COWLES ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701-5925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-452-4768
Provider Business Practice Location Address Fax Number:
907-452-1009
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COX
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
907-452-4768

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  926150 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MD6153 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: MDG543 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: NP7619 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD14421 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD69431 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: MPG0088 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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