Provider Demographics
NPI:1265465496
Name:FASBENDER, THOMAS A (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:FASBENDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8333 FELCH ST STE 202
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-2609
Practice Address - Country:US
Practice Address - Phone:616-748-2850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012865207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1651600135OtherINDIVIDUAL BLUE CROSS
MI700A610040OtherGROUP BLUE CROSS
MI4369401Medicaid
MI4369401Medicaid
MIM14680019Medicare PIN
MI0M74460234Medicare PIN
A66000040Medicare ID - Type Unspecified