Provider Demographics
NPI:1932436672
Name:FAIRBANKS PAIN CONSULTING, LLC
Entity Type:Organization
Organization Name:FAIRBANKS PAIN CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JIANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-458-5638
Mailing Address - Street 1:3030 DAVIS RD
Mailing Address - Street 2:C7
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-5233
Mailing Address - Country:US
Mailing Address - Phone:907-460-0222
Mailing Address - Fax:907-458-6415
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE 221
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-458-5638
Practice Address - Fax:907-458-6415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK124884261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2985Medicaid
AK153059Medicare PIN
AKI04806Medicare UPIN