Basic Information
| Provider Information | |||||||||
| NPI: | 1689903965 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE CLINIC OF FAIRBANKS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 MINNIE ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074567760 | ||||||||
| FaxNumber: | 9074517916 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 MINNIE ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074567760 | ||||||||
| FaxNumber: | 9074517916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2009 | ||||||||
| LastUpdateDate: | 06/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | ZAMBER | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9074567760 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 292621 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 156FX1800X | 292621 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician | 207W00000X | 292621 | AK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | A0330 | 01 | AK | BLUE CROSS | OTHER | MDG576 | 05 | AK | MEDICAID |