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General NPI Number Information
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NPI Number | 1073636148
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Entity Type | Organization
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Legal Business Name | FAIRBANKS CLINIC INC
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Dates
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Enumeration Date | 04/06/2007
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Last Update Date | 12/10/2020
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Provider Practice Location Address
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Address Line | 1405 KELLUM ST STE 201
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City | FAIRBANKS
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State | AK
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Zip | 99701-4189
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Country | US
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Telephone | 907-452-1761
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Fax | 844-531-0274
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Provider Business Mailing Address
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Address Line | 607 OLD STEESE HWY STE B307
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City | FAIRBANKS
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State | AK
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Zip | 99701-3163
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Country | US
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Telephone | 907-452-1761
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Fax | 844-531-0274
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Authorized Official
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Title or Position | OWNER
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Name | DR. TONY NIMEH
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Credential | MD
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Telephone | 617-686-6809
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 4311
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License Number State | AK
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