Provider Demographics
NPI:1992857338
Name:LITTLE TRAVERSE PSYCHIATRIC ASSOCIATES, PC
Entity type:Organization
Organization Name:LITTLE TRAVERSE PSYCHIATRIC ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-487-2415
Mailing Address - Street 1:2206 MITCHELL PARK DR
Mailing Address - Street 2:STE 10
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8674
Mailing Address - Country:US
Mailing Address - Phone:231-487-2415
Mailing Address - Fax:231-487-6569
Practice Address - Street 1:2206 MITCHELL PARK DR
Practice Address - Street 2:STE 10
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8674
Practice Address - Country:US
Practice Address - Phone:231-487-2415
Practice Address - Fax:231-487-6569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI260B41060OtherBLUE CROSS