Provider Demographics
NPI:1184702102
Name:FRIBUSH, MYRON (MD)
Entity type:Individual
Prefix:DR
First Name:MYRON
Middle Name:
Last Name:FRIBUSH
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 1:209 MOLLER AVE
Mailing Address - Street 2:MOUNTAINSIDE FAMILY HEALTHCARE
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835-7142
Mailing Address - Country:US
Mailing Address - Phone:907-747-1722
Mailing Address - Fax:907-747-1755
Practice Address - Street 1:209 MOLLER AVE
Practice Address - Street 2:MOUNTAINSIDE FAMILY HEALTHCARE
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835-7142
Practice Address - Country:US
Practice Address - Phone:907-747-1722
Practice Address - Fax:907-747-1755
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5255207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD4646Medicaid
AK8EA828Medicare PIN
AK8EA830Medicare PIN
AKMD4646Medicaid
AK8EA827Medicare PIN
B81961Medicare UPIN
AK8EA829Medicare PIN