Provider Demographics
NPI:1003366048
Name:FAIRBANKS MEMORIAL HOME MEDICAL EQUIPMENT, LLC
Entity Type:Organization
Organization Name:FAIRBANKS MEMORIAL HOME MEDICAL EQUIPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:G
Authorized Official - Last Name:SUDDUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-458-5300
Mailing Address - Street 1:1650 COWLES ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5907
Mailing Address - Country:US
Mailing Address - Phone:907-458-5421
Mailing Address - Fax:907-458-5026
Practice Address - Street 1:1701 GILLAM WAY
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-6056
Practice Address - Country:US
Practice Address - Phone:907-458-5421
Practice Address - Fax:907-458-5026
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUNDATION HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-13
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1662831Medicaid