Provider Demographics
NPI:1821084781
Name:FAIRBANKS, ROBERT KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:KENNETH
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3868
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3868
Mailing Address - Country:US
Mailing Address - Phone:509-228-1000
Mailing Address - Fax:509-252-9300
Practice Address - Street 1:601 S SHERMAN ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1311
Practice Address - Country:US
Practice Address - Phone:509-228-1000
Practice Address - Fax:509-252-9300
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000376552085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805949200Medicaid
000010032648OtherBLUE SHIELD OF IDAHO
920006292OtherRAILROAD MEDICARE
K0716OtherBLUE CROSS OF IDAHO
WA0144615OtherLABOR & INDUSTRIES
WA3070FAOtherASURIS NW HEALTH
5034131OtherAETNA
WA8243958Medicaid
920006292OtherRAILROAD MEDICARE
WAGAB20699Medicare PIN
WA0144615OtherLABOR & INDUSTRIES