Provider Demographics
NPI:1124405717
Name:FAWCETT, JOSEPH M (PA, MHSA, ATC)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:FAWCETT
Suffix:
Gender:M
Credentials:PA, MHSA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 N MAIN ST STE 3100
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311
Mailing Address - Country:US
Mailing Address - Phone:937-651-6441
Mailing Address - Fax:937-651-6442
Practice Address - Street 1:1134 N MAIN ST STE 2500
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-2382
Practice Address - Country:US
Practice Address - Phone:937-292-3494
Practice Address - Fax:937-292-3410
Is Sole Proprietor?:No
Enumeration Date:2015-05-03
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010010482255A2300X
OH50.006182RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0371852Medicaid