Healthcare Provider Details

I. General information

NPI: 1255092896
Provider Name (Legal Business Name): FAIRBANKS MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COWLES ST
FAIRBANKS AK
99701-5907
US

IV. Provider business mailing address

1650 COWLES ST
FAIRBANKS AK
99701-5907
US

V. Phone/Fax

Practice location:
  • Phone: 907-458-5597
  • Fax:
Mailing address:
  • Phone: 907-458-5597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333300000X
TaxonomyEmergency Response System Companies
License Number
License Number State

VIII. Authorized Official

Name: GARY RODERICK
Title or Position: CFO
Credential:
Phone: 907-458-3310