Basic Information
| Provider Information | |||||||||
| NPI: | 1720252026 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLENWOOD AVENUE FOOT AND ANKLE PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRUCE G FAWCETT DPM | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 GLENWOOD AVE | ||||||||
| 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: | 04/17/2008 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | FAWCETT | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9198290076 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 213EP1101X | 154 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7908064 | 05 | NC | MEDICAID |