Provider Demographics
NPI:1720252026
Name:GLENWOOD AVENUE FOOT AND ANKLE PLLC
Entity Type:Organization
Organization Name:GLENWOOD AVENUE FOOT AND ANKLE PLLC
Other - Org Name:BRUCE G FAWCETT DPM
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:919-829-0076
Mailing Address - Street 1:1514 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-2368
Mailing Address - Country:US
Mailing Address - Phone:919-829-0076
Mailing Address - Fax:919-836-9094
Practice Address - Street 1:1514 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27608-2368
Practice Address - Country:US
Practice Address - Phone:919-829-0076
Practice Address - Fax:919-836-9094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC154213EP1101X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7908064Medicaid
NCF491Medicare PIN
NC7524400001Medicare NSC