Provider Demographics
NPI:1790834828
Name:FASNACHT, ELBERT A II (MD)
Entity Type:Individual
Prefix:
First Name:ELBERT
Middle Name:A
Last Name:FASNACHT
Suffix:II
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 1:721 S LEWIS LN
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 S LEWIS LN
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
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075250207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110019903OtherRAILROAD MEDICARE
IL036075250OtherLICENSE
ILIL1280001Medicare PIN
IL036075250OtherLICENSE