Individual
DR. KENNETH J FAWCETT JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3271 CLEAR VISTA CT NE, GRAND RAPIDS, MI 49525-9477
(616) 391-7800
(616) 391-7838
Mailing address
100 MICHIGAN ST NE, MC 845, GRAND RAPIDS, MI 49503-2560
(616) 391-7800
(616) 391-7838
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
4301054239
MI
208000000X
Pediatrics Physician
4301054239
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0N10270003
MEDICARE GROUP
MI
05
—
4199704
—
MI
Enumeration date
06/09/2005
Last updated
08/28/2014
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