Basic Information
| Provider Information | |||||||||
| NPI: | 1336238336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAWCETT | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 GLENWOOD AVENUE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276082368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198290076 | ||||||||
| FaxNumber: | 9198369094 | ||||||||
| Practice Location | |||||||||
| Address1: | 1514 GLENWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276082368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198290076 | ||||||||
| FaxNumber: | 9198369094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 154 | NC | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213EP0504X | 154 | NC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Public Medicine | 213EP1101X | 154 | NC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | 213ER0200X | 154 | NC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Radiology | 213ES0000X | 154 | NC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Sports Medicine | 213ES0131X | 154 | NC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2751610 | 01 | NC | UNITED | OTHER | 08064 | 01 | NC | BCBS | OTHER | 1115086015 | 01 | NC | CIGNA | OTHER | 480017899 | 01 | NC | RAILROAD MEDICARE | OTHER | 7908064 | 05 | NC | MEDICAID | 16437 | 01 | NC | PARTNERS | OTHER | 561412156 | 01 | NC | HUMANA | OTHER | 4279205 | 01 | NC | AETNA | OTHER | 440912 | 01 | NC | OPTIMUM CHOICE | OTHER |