Basic Information
| Provider Information | |||||||||
| NPI: | 1518075100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRBANKS PSYCHIATRIC AND NEUROLOGICAL CLINIC A PROF CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1919 LATHROP ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077702301 | ||||||||
| FaxNumber: | 9077702341 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 LATHROP ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074521739 | ||||||||
| FaxNumber: | 9074522384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | BEATY | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING AGENT | ||||||||
| AuthorizedOfficialTelephone: | 9077702301 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.