1891750568 NPI number — BRADFORD W FENTON M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891750568 NPI number — BRADFORD W FENTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FENTON
Provider First Name:
BRADFORD
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1891750568
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9500 INDEPENDENCE DRIVE
Provider Second Line Business Mailing Address:
SUITE 900
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-522-1341
Provider Business Mailing Address Fax Number:
907-522-1343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9500 INDEPENDENCE DR STE 900
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99507-4686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-522-1341
Provider Business Practice Location Address Fax Number:
907-522-1343
Provider Enumeration Date:
04/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  01076617A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 35-086531 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 102803 , 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: 2588043 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4164681 . This is a "MEDICARE ID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4164682 . This is a "MEDICARE ID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 732092 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1639861 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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