Basic Information
Provider Information | |||||||||
NPI: | 1770666471 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FASANO | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | N2950 STATE ROAD 67 | ||||||||
Address2: |   | ||||||||
City: | LAKE GENEVA | ||||||||
State: | WI | ||||||||
PostalCode: | 531472655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622450535 | ||||||||
FaxNumber: | 2622452248 | ||||||||
Practice Location | |||||||||
Address1: | N2950 STATE ROAD 67 | ||||||||
Address2: |   | ||||||||
City: | LAKE GENEVA | ||||||||
State: | WI | ||||||||
PostalCode: | 531472655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622450535 | ||||||||
FaxNumber: | 2622452248 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2006 | ||||||||
LastUpdateDate: | 01/12/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 38693 | WI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 036-102882 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 38693-20 | WI | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | FASANROB | 01 | WI | MERCYCARE INSURANCE | OTHER | P00917285 | 01 | WI | RR MEDICARE | OTHER | 1770666471 | 05 | WI |   | MEDICAID | 32332100 | 05 | WI |   | MEDICAID |