Basic Information
| Provider Information | |||||||||
| NPI: | 1952366890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAHRBACH | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 92900 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972920900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032616985 | ||||||||
| FaxNumber: | 5032616790 | ||||||||
| Practice Location | |||||||||
| Address1: | 10123 SE MARKET ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032616985 | ||||||||
| FaxNumber: | 5032616790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 12/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | MD18697 | OR | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | MD18697 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 060553 | 05 | OR | MEDICAID | 8155145 | 05 | WA | MEDICAID |