Provider Demographics
NPI:1023179587
Name:EAR NOSE & THROAT CLINIC INC.
Entity Type:Organization
Organization Name:EAR NOSE & THROAT CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-456-7768
Mailing Address - Street 1:1919 LATHROP ST.
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5937
Mailing Address - Country:US
Mailing Address - Phone:907-456-7768
Mailing Address - Fax:907-456-4045
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE 103
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-456-7768
Practice Address - Fax:907-456-4045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK83561207Y00000X
207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020915Medicaid
AKMDG835Medicaid
AK6157280001Medicare NSC
AK1020915Medicaid