Provider Demographics
NPI:1790017291
Name:FAIRBANKS SURGERY, LLC
Entity Type:Organization
Organization Name:FAIRBANKS SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:MONTANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-452-8151
Mailing Address - Street 1:1919 LATHROP ST STE 204
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5942
Mailing Address - Country:US
Mailing Address - Phone:907-452-8151
Mailing Address - Fax:
Practice Address - Street 1:1919 LATHROP ST STE 204
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5942
Practice Address - Country:US
Practice Address - Phone:907-452-8151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMD1335208600000X, 2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty