NPIMap

Organization Active NPI

Ear Nose & Throat Clinic Inc.

  • Otolaryngology Physician
  • Fairbanks, AK
National Provider Identifier
1023179587
Registry record updated Dec 1, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Otolaryngology PhysicianTaxonomy code 207Y00000X
Legal business name
EAR NOSE & THROAT CLINIC INC.
Practice address
1919 Lathrop St
Suite 103
Fairbanks, AK 99701-5937
Phone
(907) 456-7768
Fax
(907) 456-4045
NPI assigned
Dec 12, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 1, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Sam Y Kim, MDNPI 1851454615
Title
President
Phone
(907) 456-7768

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Otolaryngology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Y00000X 83561 AK
Otolaryngology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Y00000X Primary

Addresses

Primary practice location

1919 Lathrop St
Suite 103
Fairbanks, AK 99701-5937

Mailing address

1919 Lathrop St.
Suite 103
Fairbanks, AK 99701-5937
Phone (907) 456-7768

Other identifiers 1

IdentifierTypeStateIssuer
1020915MedicaidAK

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AK

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040329000276 AK Part B Supplier - Clinic/Group Practice 2860384484 Receives reassigned benefits from 8 practitioners
Practice locations: Fairbanks, AK

National Provider Directory

National Provider Directory

Locations

1919 Lathrop St
Ste 104
Fairbanks, AK 99701

1001 Noble St
Ste 410
Fairbanks, AK 99701
Phone (907) 458-7768

1919 Lathrop St
Ste 103
Fairbanks, AK 99701
Phone (907) 456-7768

543 3rd Ave
#235
Fairbanks, AK 99701
Phone (907) 456-7767

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165881600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1669852800000",
    "number": "1023179587",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1919 LATHROP ST.",
            "address_2": "SUITE 103",
            "city": "FAIRBANKS",
            "state": "AK",
            "postal_code": "997015937",
            "telephone_number": "907-456-7768",
            "fax_number": "907-456-4045"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1919 LATHROP ST",
            "address_2": "SUITE 103",
            "city": "FAIRBANKS",
            "state": "AK",
            "postal_code": "997015937",
            "telephone_number": "907-456-7768",
            "fax_number": "907-456-4045"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAR NOSE & THROAT CLINIC INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-12",
        "last_updated": "2022-12-01",
        "certification_date": "2022-12-01",
        "status": "A",
        "authorized_official_last_name": "KIM",
        "authorized_official_first_name": "SAM",
        "authorized_official_middle_name": "Y",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "907-456-7768",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Otolaryngology",
            "state": "AK",
            "license": "83561",
            "primary": false
        },
        {
            "code": "207Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Otolaryngology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1020915",
            "state": "AK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fairbanks, AK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 1, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.