Provider Demographics
NPI:1134315757
Name:SAMUEL A MCCONKEY III MD PC
Entity Type:Organization
Organization Name:SAMUEL A MCCONKEY III MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCONKEY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD, PC
Authorized Official - Phone:602-375-2020
Mailing Address - Street 1:315 ILLINOIS STREET
Mailing Address - Street 2:SUITE 103B
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-2910
Mailing Address - Country:US
Mailing Address - Phone:907-456-7767
Mailing Address - Fax:907-456-8050
Practice Address - Street 1:5830 W THUNDERBIRD RD
Practice Address - Street 2:SUITE B5
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4654
Practice Address - Country:US
Practice Address - Phone:602-375-2020
Practice Address - Fax:602-978-0116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK849207W00000X
AZ27424207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKP00401344OtherMEDICARE RR
PP0401344OtherMEDICARE RAILROAD
AKMD0849Medicaid
AKC97169Medicare UPIN
AKMD0849Medicaid
AKK152587Medicare PIN
PP0401344OtherMEDICARE RAILROAD
C97169Medicare UPIN