=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285676841
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAYER CLINIC INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2006
-----------------------------------------------------
Last Update Date | 10/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1867 AIRPORT WAY SUITE 120B
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-457-5050
-----------------------------------------------------
Fax | 907-457-5034
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1867 AIRPORT WAY SUITE 120B
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-457-5050
-----------------------------------------------------
Fax | 907-457-5034
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN RICHARD MAYER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 907-457-5050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 3960
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 2974
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------