Healthcare Provider Details

I. General information

NPI: 1255652285
Provider Name (Legal Business Name): SURGERY CENTER OF FAIRBANKS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 PEGER ROAD
FAIRBANKS AK
99709
US

IV. Provider business mailing address

1905 COWLES ST
FAIRBANKS AK
99701-5914
US

V. Phone/Fax

Practice location:
  • Phone: 907-479-2663
  • Fax:
Mailing address:
  • Phone: 907-479-2663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateAK

VIII. Authorized Official

Name: DR. MARK A WADE
Title or Position: OWNER
Credential: M.D.
Phone: 907-479-2663