Provider Demographics
NPI:1962582700
Name:ELBERT A FASNACHT II MD LTD
Entity type:Organization
Organization Name:ELBERT A FASNACHT II MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELBERT
Authorized Official - Middle Name:ALVIN
Authorized Official - Last Name:FASNACHT
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:618-457-4999
Mailing Address - Street 1:721 SOUTH LEWIS LANE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3344
Mailing Address - Country:US
Mailing Address - Phone:618-457-4999
Mailing Address - Fax:618-457-5099
Practice Address - Street 1:721 SOUTH LEWIS LANE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3344
Practice Address - Country:US
Practice Address - Phone:618-457-4999
Practice Address - Fax:618-457-5099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075250207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075250Medicaid
ILDP1138OtherRAILROAD MEDICARE
IL027366OtherHEALTH ALLIANCE
IL137121OtherHEALTHLINK
IL027366OtherHEALTH ALLIANCE
IL036075250Medicaid