Provider Demographics
NPI:1437224573
Name:MOONGANG INC
Entity type:Organization
Organization Name:MOONGANG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONIE
Authorized Official - Middle Name:HORSTER
Authorized Official - Last Name:DERAMUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-452-2178
Mailing Address - Street 1:1867 AIRPORT WAY
Mailing Address - Street 2:STE 130B
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4056
Mailing Address - Country:US
Mailing Address - Phone:907-452-2178
Mailing Address - Fax:907-452-3524
Practice Address - Street 1:1867 AIRPORT WAY
Practice Address - Street 2:STE 130B
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4056
Practice Address - Country:US
Practice Address - Phone:907-452-2178
Practice Address - Fax:907-452-3524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK150527Medicare PIN