Provider Demographics
NPI:1629098140
Name:FAIRBANKS ANESTHESIA INC.
Entity Type:Organization
Organization Name:FAIRBANKS ANESTHESIA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:FLORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-945-9877
Mailing Address - Street 1:PO BOX 3750
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3750
Mailing Address - Country:US
Mailing Address - Phone:800-945-9877
Mailing Address - Fax:801-432-2670
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5998
Practice Address - Country:US
Practice Address - Phone:800-945-9877
Practice Address - Fax:801-432-2670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDG720Medicaid
AKK150148Medicare ID - Type Unspecified