Healthcare Provider Details

I. General information

NPI: 1235455809
Provider Name (Legal Business Name): FAIRBANKS ULTRASOUND, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3419 AIRPORT WAY STE D
FAIRBANKS AK
99709-4761
US

IV. Provider business mailing address

315 ILLINOIS ST
FAIRBANKS AK
99701-2910
US

V. Phone/Fax

Practice location:
  • Phone: 907-474-2002
  • Fax: 907-474-1622
Mailing address:
  • Phone: 907-456-7767
  • Fax: 907-456-8050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number935916
License Number StateAK

VIII. Authorized Official

Name: JEFFREY ALAN ZUCKERMAN
Title or Position: DIRECTOR
Credential: MD
Phone: 907-456-7767