Healthcare Provider Details

I. General information

NPI: 1629098140
Provider Name (Legal Business Name): FAIRBANKS ANESTHESIA INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COWLES ST
FAIRBANKS AK
99701-5998
US

IV. Provider business mailing address

PO BOX 3750
SALT LAKE CITY UT
84110-3750
US

V. Phone/Fax

Practice location:
  • Phone: 800-945-9877
  • Fax: 801-432-2670
Mailing address:
  • Phone: 800-945-9877
  • Fax: 801-432-2670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID RUSSELL FLORY
Title or Position: PRESIDENT
Credential: MD
Phone: 800-945-9877