1629098140 NPI number — FAIRBANKS ANESTHESIA INC.

Table of content: (NPI 1629098140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629098140 NPI number — FAIRBANKS ANESTHESIA INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRBANKS ANESTHESIA INC.
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:
1629098140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3750
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84110-3750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-945-9877
Provider Business Mailing Address Fax Number:
801-432-2670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 COWLES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701-5998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-945-9877
Provider Business Practice Location Address Fax Number:
801-432-2670
Provider Enumeration Date:
07/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLORY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
RUSSELL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
800-945-9877

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MDG720 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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