1528360625 NPI number — FAIRBANKS MEDICAL IMAGING LLC

Table of content: (NPI 1528360625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528360625 NPI number — FAIRBANKS MEDICAL IMAGING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRBANKS MEDICAL IMAGING LLC
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:
1528360625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1320 E DIVISION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98274-4133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-424-6161
Provider Business Mailing Address Fax Number:
360-848-1167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2310 PEGER RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99709-5305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-424-6161
Provider Business Practice Location Address Fax Number:
360-848-1167
Provider Enumeration Date:
11/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BURKE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
360-424-6161

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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