1336238336 NPI number — DR. BRUCE G FAWCETT DPM

Table of content: DR. BRUCE G FAWCETT DPM (NPI 1336238336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336238336 NPI number — DR. BRUCE G FAWCETT DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAWCETT
Provider First Name:
BRUCE
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336238336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1514 GLENWOOD AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27608-2368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-829-0076
Provider Business Mailing Address Fax Number:
919-836-9094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1514 GLENWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27608-2368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-829-0076
Provider Business Practice Location Address Fax Number:
919-836-9094
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  154 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213EP0504X , with the licence number: 154 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213EP1101X , with the licence number: 154 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ER0200X , with the licence number: 154 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0000X , with the licence number: 154 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0131X , with the licence number: 154 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2751610 . This is a "UNITED" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 08064 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1115086015 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 480017899 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7908064 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 16437 . This is a "PARTNERS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 561412156 . This is a "HUMANA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 4279205 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 440912 . This is a "OPTIMUM CHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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