Provider Demographics
NPI:1770666471
Name:FASANO, ROBERT A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:FASANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2950 STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2655
Mailing Address - Country:US
Mailing Address - Phone:262-245-0535
Mailing Address - Fax:262-245-2248
Practice Address - Street 1:N2950 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2655
Practice Address - Country:US
Practice Address - Phone:262-245-0535
Practice Address - Fax:262-245-2248
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38693207R00000X
IL036-102882207R00000X
WI38693-20208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIFASANROBOtherMERCYCARE INSURANCE
WIP00917285OtherRR MEDICARE
WI1770666471Medicaid
WI32332100Medicaid
WI1770666471Medicaid
WI014400219Medicare PIN
G52567Medicare UPIN
WI32332100Medicaid