Provider Demographics
NPI:1952763153
Name:FERNSTRUM, AUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:FERNSTRUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11100 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1716
Mailing Address - Country:US
Mailing Address - Phone:216-844-1000
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST STE M-318
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5383
Practice Address - Country:US
Practice Address - Phone:269-349-9745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301506846208800000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program