Basic Information
| Provider Information | |||||||||
| NPI: | 1184702102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRIBUSH | ||||||||
| FirstName: | MYRON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 MOLLER AVE | ||||||||
| Address2: | MOUNTAINSIDE FAMILY HEALTHCARE | ||||||||
| City: | SITKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998357142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077471722 | ||||||||
| FaxNumber: | 9077471755 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 MOLLER AVE | ||||||||
| Address2: | MOUNTAINSIDE FAMILY HEALTHCARE | ||||||||
| City: | SITKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998357142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077471722 | ||||||||
| FaxNumber: | 9077471755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 08/15/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 5255 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD4646 | 05 | AK | MEDICAID |