Basic Information
| Provider Information | |||||||||
| NPI: | 1912458696 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRBANKS MEMORIAL HOSPITAL, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAIRBANKS MEMORIAL HOSPITAL HOME CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 COWLES ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074585525 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1650 COWLES ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074585525 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2016 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RODERICK | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9074583310 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FOUNDATION HEALTH, LLC | ||||||||
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| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
No ID Information.