Provider Demographics
NPI:1386193472
Name:FAIRBANKS MEMORIAL CARDIOLOGY CENTER, LLC
Entity Type:Organization
Organization Name:FAIRBANKS MEMORIAL CARDIOLOGY CENTER, 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:SUDUTH
Authorized Official - Suffix:
Authorized Official - Credentials:CPA, FHFMA, FACHE
Authorized Official - Phone:907-458-3310
Mailing Address - Street 1:1650 COWLES ST DEPT 60A
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:907-458-5525
Mailing Address - Fax:
Practice Address - Street 1:1650 COWLES ST DEPT 60A
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5907
Practice Address - Country:US
Practice Address - Phone:907-458-5525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUNDATION HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-29
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty