Basic Information
| Provider Information | |||||||||
| NPI: | 1588693717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FASCI | ||||||||
| FirstName: | SIV | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4105 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669071068 | ||||||||
| FaxNumber: | 4259179141 | ||||||||
| Practice Location | |||||||||
| Address1: | 3340 PROVIDENCE DR STE A567 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072128366 | ||||||||
| FaxNumber: | 9072128499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 125264 | AK | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | L6882 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0006X | L6882 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics | 2080P0006X | 125264 | AK | Y | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 160063706 | 05 | TX | MEDICAID |