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General NPI Number Information
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NPI Number | 1962582700
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Entity Type | Organization
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Legal Business Name | ELBERT A FASNACHT II MD LTD
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Dates
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Enumeration Date | 10/16/2006
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Last Update Date | 09/10/2009
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Provider Practice Location Address
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Address Line | 721 SOUTH LEWIS LANE
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City | CARBONDALE
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State | IL
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Zip | 62901-3344
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Country | US
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Telephone | 618-457-4999
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Fax | 618-457-5099
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Provider Business Mailing Address
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Address Line | 721 SOUTH LEWIS LANE
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City | CARBONDALE
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State | IL
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Zip | 62901-3344
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Country | US
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Telephone | 618-457-4999
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Fax | 618-457-5099
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Authorized Official
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Title or Position | PRESIDENT
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Name | ELBERT ALVIN FASNACHT II
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Credential | MD
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Telephone | 618-457-4999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036075250
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License Number State | IL
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