Provider Demographics
NPI:1568525764
Name:FABAZ, ANTHONY G (DO)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:G
Last Name:FABAZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5 N ATKINSON DR STE 304
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2918
Mailing Address - Country:US
Mailing Address - Phone:231-843-2600
Mailing Address - Fax:231-843-2665
Practice Address - Street 1:5 N ATKINSON DR
Practice Address - Street 2:SUITE 304
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2918
Practice Address - Country:US
Practice Address - Phone:231-843-2600
Practice Address - Fax:231-843-2665
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF006766208G00000X
MI51010067662086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6164460001Medicare NSC