Provider Demographics
NPI:1912010687
Name:MAT-SU EAR, NOSE, THROAT & FACIAL PLASTICS, INC.
Entity Type:Organization
Organization Name:MAT-SU EAR, NOSE, THROAT & FACIAL PLASTICS, INC.
Other - Org Name:FACIAL PLASTIC ENT & ASSOCIATES, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:PULLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-745-9200
Mailing Address - Street 1:2490 SOUTH WOODWORTH LOOP
Mailing Address - Street 2:201
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645
Mailing Address - Country:US
Mailing Address - Phone:907-745-9200
Mailing Address - Fax:907-745-9201
Practice Address - Street 1:2490 SOUTH WOODWORTH LOOP
Practice Address - Street 2:201
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645
Practice Address - Country:US
Practice Address - Phone:907-745-9200
Practice Address - Fax:907-745-9201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4516174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD3510Medicaid
AK1020801Medicaid
AKK160457Medicare ID - Type Unspecified