Provider Demographics
NPI:1942751631
Name:FAIRBANKS MEMORIAL CARDIOLOGY CLINIC, LLC
Entity Type:Organization
Organization Name:FAIRBANKS MEMORIAL CARDIOLOGY CLINIC, LLC
Other - Org Name:FAIRBANKS MEMORIAL PHYSICIAN SPECIALTIES
Other - Org Type:Other Name
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:EBENAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-458-5550
Mailing Address - Street 1:1650 COWLES ST DEPT 61A
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5907
Mailing Address - Country:US
Mailing Address - Phone:907-458-6453
Mailing Address - Fax:
Practice Address - Street 1:1650 COWLES ST DEPT 61A
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5907
Practice Address - Country:US
Practice Address - Phone:907-458-6453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUNDATION HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty