Provider Demographics
NPI:1134990336
Name:A4 SPECIALTY MEDICAL GROUP FAIRBANKS LLC
Entity type:Organization
Organization Name:A4 SPECIALTY MEDICAL GROUP FAIRBANKS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-744-1944
Mailing Address - Street 1:510 W TUDOR RD STE1
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-6649
Mailing Address - Country:US
Mailing Address - Phone:907-744-1944
Mailing Address - Fax:907-921-7669
Practice Address - Street 1:282 BENTLEY TRUST ROAD SUITE B
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-744-1944
Practice Address - Fax:907-921-7669
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A4 SPECIALTY MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-16
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty