Basic Information
| Provider Information | |||||||||
| NPI: | 1225027535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAWCETT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 MULBERRY ST | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477131252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124217489 | ||||||||
| FaxNumber: | 8124360209 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 JOHN ST | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477132733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124360224 | ||||||||
| FaxNumber: | 8124360230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 23450 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 01030700A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200065860 | 05 | IN | MEDICAID | 64234503 | 05 | KY | MEDICAID |