1184691743 NPI number — TANANA VALLEY MEDICAL SURGICAL GROUP INC

Table of content: (NPI 1184691743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184691743 NPI number — TANANA VALLEY MEDICAL SURGICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TANANA VALLEY MEDICAL SURGICAL GROUP 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:
6
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:
1184691743
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 NOBLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRBANKS
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99701-4922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-459-3507
Provider Business Mailing Address Fax Number:
907-459-3532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 NOBLE 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:
99701-4922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-459-3507
Provider Business Practice Location Address Fax Number:
907-459-3532
Provider Enumeration Date:
03/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHILL
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
907-459-3509

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0118 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: CE7854 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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