Provider Demographics
NPI:1851486930
Name:FAASE, MARIA ELISABETH (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ELISABETH
Last Name:FAASE
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 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5215 HOLY CROSS PKWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1469
Practice Address - Country:US
Practice Address - Phone:574-335-4145
Practice Address - Fax:574-335-4146
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0381452080N0001X
IN010721652080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00685913HMedicaid
GA038145OtherGA LICENSE NUMBER
IN201222680Medicaid
IN000000925186OtherBCBS NICU
IN000000859438OtherBCBS
IN000000859438OtherBCBS