Provider Demographics
NPI:1316114549
Name:DR. T. FELLENBAUM M.D. & OB/GYN ASSOCIATES, P.C.
Entity type:Organization
Organization Name:DR. T. FELLENBAUM M.D. & OB/GYN ASSOCIATES, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MISKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-733-8200
Mailing Address - Street 1:3500 CALKINS RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3500
Mailing Address - Country:US
Mailing Address - Phone:810-733-8200
Mailing Address - Fax:810-221-1751
Practice Address - Street 1:3500 CALKINS RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3500
Practice Address - Country:US
Practice Address - Phone:810-733-8200
Practice Address - Fax:810-221-1751
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. T FELLENBAUM M.D. AND OB/GYN ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-16
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056913207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1602513951OtherBLUE CARE NETWORK (BCN) BLUE CHOICE
MI1606365292OtherHEALTH PLUS OF MICHIGAN (HGH) MEDICAID
MI1602513951OtherBLUE CROSS BLUE SHIELD OF MICHIGAN PPO TRUST
MI1606365292OtherHEALTH PLUS OF MICHIGAN MEDICARE
MI1606365292OtherGENESEE HEALTH PLAN (GHP)
MI15289OtherHEALTH PLAN OF MICHIGAN
MI1602513951OtherBLUE CARE NETWORK (BCN) COMMERCIAL
MI1602513951OtherBLUE CARE NETWORK (BCN) MEDICARE ADVANTAGE
MIF24353OtherHEALTH ALLIANCE PLAN (HAP) COMMERCIAL
MI1606365292OtherHEALTH PLUS OF MICHIGAN COMMERCIAL
MIF24353OtherHEALTH ALLIANCE PLAN (HAP) PHP
MI123042OtherPREFERRED CHOICES
MI1366457848OtherMOLINA
MI1602513951OtherBLUE CROSS BLUE SHIELD OF MICHIGAN ADVANTAGE
MI1606365292OtherHEALTH PLUS OF MICHIGAN PPO
MI1602513951OtherBLUE CROSS BLUE SHIELD OF MICHIGAN TRADITIONAL
MI1602513951OtherBLUE CARE NETWORK (BCN) BLUE PREFERRED PLUS