Provider Demographics
NPI:1578601340
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:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCONKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-456-7767
Mailing Address - Street 1:315 ILLINOIS ST
Mailing Address - Street 2:
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 1:1521 STACIA ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-6135
Practice Address - Country:US
Practice Address - Phone:907-456-4822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK849207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0849Medicaid
AZC97169Medicare UPIN
AZ72858Medicare ID - Type Unspecified
AK152587Medicare ID - Type Unspecified
AKMD0849Medicaid