Provider Demographics
NPI:1881723807
Name:FAIRBANKS MEMORIAL CARDIOLOGY CENTER
Entity type:Organization
Organization Name:FAIRBANKS MEMORIAL CARDIOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-747-4000
Mailing Address - Street 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:SUITE 60A
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5925
Practice Address - Country:US
Practice Address - Phone:907-458-5525
Practice Address - Fax:970-458-5514
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-05
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK161047Medicare PIN