Healthcare Provider Details

I. General information

NPI: 1821084781
Provider Name (Legal Business Name): ROBERT KENNETH FAIRBANKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 6TH ST
LEWISTON ID
83501-2439
US

IV. Provider business mailing address

PO BOX 239
LEWISTON ID
83501-0239
US

V. Phone/Fax

Practice location:
  • Phone: 208-799-5600
  • Fax: 208-799-5755
Mailing address:
  • Phone: 208-799-5600
  • Fax: 208-799-5755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD00037655
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: