Provider Demographics
NPI:1699032284
Name:FASS, MICHELE (MD)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:
Last Name:FASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:KY
Mailing Address - Zip Code:60667-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5573
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:115 HUSTON DR. STE1
Practice Address - Street 2:
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-7520
Practice Address - Country:US
Practice Address - Phone:502-955-7311
Practice Address - Fax:502-955-9694
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine