Provider Demographics
NPI:1629240874
Name:ORTHOPAEDIC TRIAGE OF FAIRBANKS, INC
Entity Type:Organization
Organization Name:ORTHOPAEDIC TRIAGE OF FAIRBANKS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:907-452-4446
Mailing Address - Street 1:1919 LATHROP, SUITE 209
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-452-4469
Mailing Address - Fax:907-451-9480
Practice Address - Street 1:1919 LATHROP, SUITE 209
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-452-4469
Practice Address - Fax:907-451-9480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD45451Medicaid
AKR73968Medicare UPIN
AKMD45451Medicaid