Provider Demographics
NPI:1659687945
Name:FAIRBANKS FOOT & ANKLE INC.
Entity Type:Organization
Organization Name:FAIRBANKS FOOT & ANKLE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:SYLVAN
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:907-451-9202
Mailing Address - Street 1:1405 KELLUM ST.
Mailing Address - Street 2:STE 200
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-451-9202
Mailing Address - Fax:907-452-6256
Practice Address - Street 1:1405 KELLUM ST.
Practice Address - Street 2:STE 200
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-451-9202
Practice Address - Fax:907-452-6256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2810213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPD2810Medicaid
AKPD2810Medicaid