1316114549 NPI number — DR. T. FELLENBAUM M.D. & OB/GYN ASSOCIATES, P.C.

Table of content: (NPI 1316114549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316114549 NPI number — DR. T. FELLENBAUM M.D. & OB/GYN ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. T. FELLENBAUM M.D. & OB/GYN ASSOCIATES, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MID-MICHIGAN VULVAR CARE AND COLPOSCOPY CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316114549
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4520 LINDEN CREEK PKWY
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48507-2969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-733-8200
Provider Business Mailing Address Fax Number:
810-733-8272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4520 LINDEN CREEK PKWY
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48507-2969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-733-8200
Provider Business Practice Location Address Fax Number:
810-733-8272
Provider Enumeration Date:
05/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MISKE
Authorized Official First Name:
DONOVAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
810-733-8200

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  4301056913 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1606365292 . This is a "HEALTH PLUS OF MICHIGAN PPO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1602513951 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN PPO TRUST" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1602513951 . This is a "BLUE CARE NETWORK (BCN) BLUE PREFERRED PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1606365292 . This is a "HEALTH PLUS OF MICHIGAN COMMERCIAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1606365292 . This is a "GENESEE HEALTH PLAN (GHP)" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: F24353 . This is a "HEALTH ALLIANCE PLAN (HAP) PHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1602513951 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN ADVANTAGE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1602513951 . This is a "BLUE CARE NETWORK (BCN) BLUE CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 123042 . This is a "PREFERRED CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1606365292 . This is a "HEALTH PLUS OF MICHIGAN MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1606365292 . This is a "HEALTH PLUS OF MICHIGAN (HGH) MEDICAID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1366457848 . This is a "MOLINA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: F24353 . This is a "HEALTH ALLIANCE PLAN (HAP) COMMERCIAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1602513951 . This is a "BLUE CARE NETWORK (BCN) MEDICARE ADVANTAGE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1602513951 . This is a "BLUE CARE NETWORK (BCN) COMMERCIAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1602513951 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN TRADITIONAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 15289 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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